A 



-A 



NERVOUS DISEASES: 



THEIR 



Descrtption and Treatment. 



A Mannal for Stnileiits and Practitioiers of Meticine. 



BY ^-^ 

ALLAIS^ McLAlSTE HAMILTOlS, M.D., 

FKLLOW OF THE NEW YORK ACADEMY OF MEDICINE; ONE OF THE ATTENDING PHYSICIANS AT TllK 

HOSPITAL FOR EPILEPTICS AND PARALYTICS, BLACKWELL'S ISLAND, NEW YORK CITY; ONE OF 

THE CONSULTING PHYSICIANS AT THE HtfDSON RFV^ES STATE HOSPITAL FOB THE INSANE, 

AND MALE AND FEMALE INSANE ASYLUMS OF NEW YORK CITY, ETC., ETC., ETC. 



"Tf SECOND EDITION— REVISED AND ENLARGED. 



With Seventy-two Illustrations. 





PHILADELPHIA: 

HEIvTEY C. LEA%S SOI^ & CO 

1881. 



I - 



Entered according to Act of Congress, in the year 1881, by 

HENRY C. LExl'S SON &C0, 

In the Ottice of the Librarian of Congress. All rights reserved 



Grant, Faikks & Rddgkrs, 
E'ectroti,qw.s and Printers, 
52 & 54 North Sixth Street. 



TO MY FRIENDS 



FORDYCE BARKER, M. D., 



JOHN T. METCALFE, M. D 



AND TO 



MEREDITH CLYMER, M.D., 

THE PIONEER 
IN THE FIELD OF MODERN NEUROLOGICAL LITER ATFRE IN AMERICA, 



PREFACE TO THE SECOND EDITION. 



In pj-esentiiig a new edition of my book I wish to express to 
the profession my hearty appreciation of the favorable reception 
accorded to the first, which has been out of print for several months. 
I thank my impartial reviewers, and take pleasure in saying that 
wlierever possible, I have endeavored to adopt their suggestions, 
and I trust, have succeeded in remedying tlie faults, many of whicli 
are unavoidable in a first edition. 

The present edition is enlarged by nearly one hundred pages 
and contains many new illustrations, in fact this feature of the 
book has undergone an almost entire change. The enlargement is 
a matter of necessity, omng to the recent advances in our know- 
ledge of neurological medicine. I liave used certain portions of my 
essay which received the prize of the American Medical Association, 
in 1879, in the preparation of a chapter upon diseases of the lateral 
columns of the spinal cord. Other chapters have been remodeled, 
and I hope improved, especially in regard to the introduction of 
matter relative to localization of disease in the brain and spinal 

<;ord. 

ALLAN McLANE HAMILTON, 

New York, 43 East 33d St. 
Nov. 1st, 188L 



PREFACE TO THE FIRST EDITION. 



It has been my object to produce a concise, practical book; and 
should the satisfaction be ever accorded me of knowing that I have 
made the subjects of Diagnosis and Treatment of ^N^ervous Diseases 
more simple to my readers than I think they now are, I shall be 
amply rewarded for the task I have undertaken. 

I have not considered Insanity, because I believe that this subject 
deserves much more extended notice than it could possibly receive in 
a book of this size and kind. 

I have deemed it advisable to include a short article upon Cerebro- 
spinal Meningitis, though, by many authorities, it is not regarded, 
strictly speaking, as a nervous disease. I think, if for no other 
reason, its interesting diagnostic relations entitle it to consideration. 

In conclusion, I wish to thank Drs. Loring, Janeway, Mason, 
Shakespeare, my resident physicians, Drs. JNIeyer, Xaylor, Ryan, and 
Baldwin, and Mr. F. O. C. Darley, for valuable assistance in the 
preparation of this volume. 

• ALLAN McLANE HAMILTON. 



CONTENTS 



INTRODUCTION. 

PAGB 

I. Hints in regard to Methods of Examination and Study — Examma- 
tion of the patient, symptomatology, etc. — Autopsical and microscopical 
examinations . 17-21 

II. Instruments used for the Diagnosis and Treatment of Nervous 
Diseases — The Thermometer, ^sthesiometer, Dynamometer, Ophthalmo- 
scope, The Percussion hammer — Apparatus for the Treatment of Ner- 
vous Diseases — Electrical, Rubber Muscles, Hypodermic Syringe, Ether- 
Spray Apparatus, Spinal and Cranial Ice-bags, Cauteries, etc. . . 22-37 

CHAPTER 1. 

diseases of the cerebral meninges. 

Cerebral Pachymeningitis — Acute, chronic — Chronic Pachymeningitis with 
haematoma — Acute Cerebral Meningitis, basal, vertical — Rheumatic Menin- 
gitis — Meningitis of the Aged — Acute Granular (Tubercular) Meningitis — 
Acute granular meningitis of the convexity — Chronic Cerebral Meningitis 38-75 

CHARTER II. 

diseases of the cerebrum and cerebellum. 

Symptomatic Cerebral Hypercemia — Cerebral Hemorrhage . . . 76-126 

CHAPTER III. 

diseases of the cerebrum and cerebellum ""(continued). 

Symptomatic Cerebral Anaemia (acute, chronic, infantile) — Stomachic Vertigo 
— Auditory Vertigo 127-144 

CHAPTER IV. 

diseases of the cerebrum and cerebellum (continued). 

Occlusion of Intra-Cranial Vessels — Thrombosis — Embolism — Throm- 
bosis of the Cerebral Arteries — Thrombosis of Sinuses and Veins — Embol- 
ism 0/ the Cerebral Vessels ^ 145-163 

xi 



Xll CONTENTS. 

CHAPTER V. 

DISEASES OF THE CEREBRUM AND CEREBELLUM (CONTINUED). 

PAOK 

Cerebral Softening — Acute, chronic — Asemasia (aphasia) — Cerebral Scle- 
rosis — Diffused Cerebral Sclerosis ■ 163-204 

CHAPTER VI. 

DISEASES OF THE CEREBRUM AND CEREBELLUM (CONCLUDED). 

Brain Tumors — Cerebellar Hemorrhage — Tumors of the Cerebellum — Soften- 
ing and Abscess of the Cerebellum 205-235 

CHAPTER VII. 

DISEASES OF THE SPINAL MENINGES. 

Spinal Meningitis (acute pachymeningitis) — Acute and Chronic Spinal 
Meningitis — Spinal Pachymeningitis — Spinal Tmnors — Spinal Hemorrhage 
meningeal, central 236-254 

CHAPTER VIII. 

DISEASES OF THE SPINAL CORD. 

Spinal Hypercemia Spinal Congestion, Subacute Spinal Hyperaemia — 
Spinal Irritation . . ' 255-264 

CHAPTER IX. 

DISEASES OF THE SPINAL CORD (CONTINUED). 

Inflammation of the Spinal Cord — Myelitis — acute, chronic — Acute Ascend- 
ing Paralysis — Antero-Spinal Parcdysis of Infants — Of Adults . 265-294 

CHAPTER X. 

DISEASES OF THE, SPINAL CORD (CONTINUED). 

Progressive Muscular Atrophy— Partial Facial Atrophy — Pse^ido- Hyper- 
trophic Muscular Paralysis 295-320 

CHAPTER XI. 

DISEASES OF THE SPINAL CORD (CONTINUED). 

Posterior Spinal Sclerosis (Locomotor Ataxia) — Sclerosis of the columns of- 
GoU — Antero- Lateral Amyotrophic Sclerosis 321-346 

CHAPTER XII. 

DISEASES OF THE SPINAL CORD (CONCLUDED). 

Infantile Spastic Paralysis — Functional Disease of the Lateral Columns- 
Hysterical Spasmodic Spinal Paralysis — Primary Degeneration of the 
Lateral Columns — Tetanus 347-383 



CONTENTS. xm 

CHAPTER XIII. 

BULBAR DISEASES. 

PAGE 

Epilepsy — Bulbar Paralysis 384-420 

CHAPTER XIV. 

. CEREBRO-SPINAL DISEASES. 

Cerehro- Spinal Meningitis — Cerebro- Spinal Sclerosis — Alcoholism — acute 
— chronic — Nicotinism — Hydrophobia — Hysteria — Hystero-Epilepsy — 
Catalepsy . 421-482 

CHAPTjER XV. 

CEREBKO-SPIXAL DISEASES (CONCLUDED). 

Chorea — Paralysis Agitans — Exophthalmic Goitre .... 483-510 

CHAPTER XVI. 

DISEASES OF THE PERIPHERAL NERVES. 

Xeuralgia, facial, cervico-occipital, cervico-brachial, intercostal, or pleuro- 
dynia — Sciatic — Crural, visceral, ovarian, urethral, renal, etc. . . 511-537 

CHAPTER XVII. 

DISEASES OF THE PERIPHERAL NERVES (CONTINUED). 

yeimtis — Ancesthesia — Tumors of Nerves 538-547 

CHAPTER XVIII. 

DISEASES OF THE PERIPHERAL NERVES (CONTINUED). 

Local Paralysis — Facial paralysis — Traumatic paralysis — Diphtheritic 
paralysis ............ 548-5G5 

CHAPTER XIX. 

DISEASES OF THE PERIPHERAL NERVES (CONCLUDED). 

Lead Poisoning — Functional Spasm — Tetany — Functional spasm with vol- 
untary movements: — Reflex spasm — Facial spasm without pain — Torticollis 
— Professional Cramp — Writer's Cramp — Dancer's Cramp — Telegrapher's 
Cramp, etc., etc. — (Esophagismiis . . . • . . . . 566-587 



LIST OF ILLUSTRATIONS. 



no. rAUK 

1. Seguin's Surface Thermometer 22 

2. Gray's System of Head Straps 23 

3. SiSVEKING's iEsTHESIOMETER , 26 

4. Diagram for making Records 28 

5. Mathieu's Dynamometer , 2V» 

6. The Author's Dynamometer 30 

7. Loring's Ophthalmoscope 31 

8. Percussion Hammer . , 33 

9. Manner of Testing Tendon-reflex. (Goivers) 3i 

10. The Author's Gas Cautery 36 

11. Osteoma OF Dura Mater. (Lancereaux) 43 

12. Tuberculous Matter about Vessels. {Corniland Banvier). ..... ^(i 

13. Distended Perivascular Spaces. {Fothergill) 86 

14. 15. Tracings of Patellar Tendon-Reflex. (Brissaud) 101 

16. Cortical Centres. {Morel) - . 105 

17. Charcot's Scheme of Cerebral Motor Tracts ; 107 

18. Internal Cerebral Vascular Supply. {Charcot) 110 

19. External Cerebral Vascular Supply. {Charcot) Ill 

20. Miliary Aneurisms 113 

21. Multiple Lesions with Tongue Atrophy • . . 117 

22. Instrument for Applying Heat and Cold 126 

23. Tissue Changes in Softening 175 

24. Handwriting of Agraphic Patient. {Bourneville) . 184 

25. Handwriting of Patient with Cerebro-Spinal Sclerosis and Agraphia 184 

26. Plate Showing Third Frontal Convolution. {Bateman) 186 

27. Choked Disk. {After Leibreich) 208 

28. Plate Showing Decussation of Optic Nerve Fibres. {Charcot) . . . 209 

29. Tubercular Deposit 212 

30. Sarcoma of Brain 212 

31. Gumma of Brain ; . . . 213 

32. Psammoma of Brain 2l.') 

33. Encephaloid of Brain 213 

34. Glioma of Brain 213 

34a. Cerebellar Aneurisms. {Bristowe) 229 

35. Deformity of Hand in Cervical Pachymeningitis. {Charcot). .... 238 

36. Scheme of Conductors in Cord 246 

XV 



XVI LIST OF ILLUSTRATIONS. 

IG. PACK 

37. Diagram Showiitg Relation of Motor, Sensory, and Reflex Functions 

OF Cord. (Oowers) 273 

38-41. Muscular Changes in Antero-Spinal Paralysis of Infants. 

{Buckenne) 284 

42. Antero-Spinal Paralysis. [Seguin) . - 287 

43. Main en Griffe. {DucJienne) 296 

44. Perimeter of Chest in Progressive Muscular Atrophy. {Duehcnne) . 30(» 

45. Atrophy of Left Shoulder 208 

46. Partial Facial Atrophy 300 

47. Pseudo-Hypertrophic Paralysis. (Gowers) . , . . 314 

48. Mechanics of Muscular Action in Pseudo-Hypertrophic Paralysis. 

(Gowers) 3i() 

49. Appearance of Muscular Tissue in Pseudo-Hypertrophic Paralysis. 

(Charcot) 319 

50. Appearance of Trophic Changes in Locomotor Ataxia. (Charcot) . . . 332 

51. Course of Posterior Nerve-Root Fibres. (Clarke). 335 

52. Sclerosis of Columns of Goll. (Charcot) 341 

53. Method of Provoking Dorsal Clonus. (Govjers) 350 

54. Contraction of Feet in an Advanced Case of Primary Degenera- 

tion OF the Lateral Columns 357 

55. Syringo-Myelia and Hydro-Myelia. (Leyden) 360 

56. Scheme of Fibre Connection in Lateral Columns. (Flechsig) .... 361 

57. Sclerosis of Lateral Columns Sc;; 

58. Map of Suffolk Co., Long Island, Showing Prevalence of Endemic 

tetanus . 37h 

59. Retraction of Head in Cerebro-Spinal Meningitis. (Lewis Smith) . . 422 

60. The Pathology of Hysteria 467 

61-64. Attitudes of Hystero-Epileptic. (Boumeville and liegnard) . . 471-475 

65. Exophthalmic Goitre ( Yeo) . 505 

66. Charts Showing Nervous Areas. (After Herde) 532 

67. The Author's Percuteur 535 

68. Trophic Changes of Skin of Hand in Neuritis 539 

69. Sarcomatous Neuroma. (Foucault) 547 

70. Wire Hook for Treating Facial Paralysis 55;') 

71. Reflex Spasm from Genital Irritation 577 

72. Instrument Used for Treatment of Torticollis 58U 



NERVOUS DISEASES. 



INTRODUCTION. 

HINTS IN KEGAKD TO METHODS OF EXAMINATION 
AND STUDY. 

In beginning our consideration of the diseases which are to form the 
subject of the succeeding pages, it is well to start with systematic rules 
for investigation, and it is of paramount importance that we should pursue 
some plan which will enable us to avoid confusion, and assist us in making 
an accurate diagnosis by exclusion. I, therefore, propose a scheme to be 
used in the examination of patients, and would add a word of caution in 
regard to the error many of us make in too readily accepting and isolating 
nervous symptoms as distinct, which, after all, may be expressions of some 
general disorder. It too often happens that simple digestive disturbances, 
cholesterseraia, or perhaps ur?emic poisoning give rise to symptoms that are 
seized upon as the basis of a distinct nervous disease, and the error is not 
recognized in time to arrest the true mischief. 

We are to determine the existence and relation of disorders of motility 
and sensation, as well as mental symptoms, defects of speech, sight, or 
hearing, together with the causes which enter into their production. 

EXAMINATION OF THE PATIENT. 

Preliminary Examination. — Sex, age, temperament, appearance, 
duration of present disease, existence of complicating maladies, previous 
history, hereditary predisposition, habits. 

SYMPTOMATOLOGY. 

Motility, degree of, location of loss or increase (one side or one-half 
^of body?), groups of muscles or single muscles, face, trunk, or extremities, 
lateral or bilateral, symmetrical or unsymmetrical, loss or exaggeration 
of electro-muscular contractility, fibrillary contractions, muscular power, 
associated with deformities or contractures; atrophy or hypertrophy, gen- 
eral or partial ; spasms, tonic or clonic, attended or unattended by loss of 
consciousness; condition of reflex excitability. 

Tremor. — Local or general, increased or controlled by will, "fine" or 
" coarse;" time of day, continuous or at intervals; subsidence or continu- 
ance during sleep; whether evoked by jarring limb, or by tapping tendons 
or muscles; increased or stopped by flexion or extension of foot; accom- 
panied or not by pain ; associated or not with rigidity of joints when limb 
is flexed 

2 17 



18 INTRODUCTION. 

Incodrdiriation of upper or lower extremities, variety of action in which 
it occurs ; gait ; aggravation by closure of eyes ; loss of muscular sense ; 
loss of locating power. 

Sensation. — General or partial anaesthesia; dyssesthesia or hyperses- 
thesia ; susceptibility to painful impressions ; temperature ; tactile sensibili- 
ty ; sensibility to pressure ; pain, localized or general ; character of pain, 
neuralgic, terebrating, dull, or paroxysmal ; time when aggravated ; its 
associations ; time of transmission of sensation ; appreciation of form. 

Disorders of Organs of Special Sense. 

Eyes. — Nystagmus, strabismus, conjugate deviation (see article Cere- 
bral Hemorrhage), retinal changes, corneal changes, pupillary changes, 
ptosis, diplopia, amblyopia, amaurosis. The existence of color blindness. 

Ear. — Deafness, subjective noises, discharge. 

Speech. — Aphasia, slow speech, clumsy speech, ataxic speech, loss of 
speech (mutism). Visual and auditory relations. 

Vertigo. — Variety ; concomitant phenomena. 

Psychical Disorders. — Illusion, hallucination, delirium, mania, me- 
lancholia, delusions, and their character, loss of memory, loss of con- 
sciousness, imbecility, idiocy, excitability, dementia. 

Miscellaneous. — Character of cutaneous surface, changes in tempera- 
ture of general surface or localized spots, cranial temperature, variation 
in salivary secretions, changes in pigmentation and appearance of hair, 
perspiration, etc. 

Exciting Causes ; Diagnosis ; Treatment. 

This list, though imperfect, will, I think, enable the observer to pursue 
a systematic course in examining his patient. He should, at the same 
time, take careful notes for future reference, so that variations in the 
symptoms and changes of treatment may be remembered. 

Before leaving the subject of examination, I wish to refer to the value 
of post-mortem examination and microscopical investigation of the morbid 
anatomical changes. These subjects belong more properly to special works 
upon pathology and microscopy, but it may not be amiss to add a few hints 
to those already given in regard to certain important steps to be taken. In 
removing the calvarium the thickness of the cranial bones should be noted, 
as well as the condition of the diploe ; but extreme care should be em 
ployed, in sawing through the bone, not to wound the meninges and brain- 
substance beneath; for the saw-teeth may unexpectedly tear through, 
lacerating and injuring these parts, so that they may be almost useless 
for subsequent examination. After the skullcap has been removed, the 



POST-MORTEM EXAMINATION. 19 

observer should be on the lookout for Pacchonian bodies, and ready to re- 
cognize any adventitia that may be attached to the dura mater. The condi- 
tion of the longitudinal sinus and veins which are contained in the dura ma- 
ter should be examined as to their fulness, etc. ; the thickness, vascularity, 
color, and opacity of their tissue should also be carefully noted and then an 
incision may be made, and this membrane slit up with a pair of blunt- 
pointed scissors, or it may be cut around at the level of the saw cut. 
The arachnoid and pia mater are- then to be inspected: the existence of 
effusion, either serous, purulent, or bloody; and the presence of granular 
deposit or vascular changes noted. The brain should be lifted back, and 
the cranial nerves carefully cut as near as possible to their points of exit 
from the skull, the optic first, and then the carotid arteries and posterior 
nerves ; next the tentorium, and finally the other nerves, vertebral arte- 
ries, and the spinal cord as low down as possible, taking care not to make 
pressure by insinuating the finger into the foramen maguum. The brain 
may then be removed.^ If it is desired to remove the cord, the skin and 
muscular tissue of the back should be divided and thrown back, and the 
spinous processes and laminae exposed. These latter should be sawn 
through on each side and carefully raised by the blade of the chisel^ 
When the brain is removed, it should be placed with the base downwards ^ 
and the appearance of the convolutions noted, the membranes having 
been removed. Evidences of pressure are to be looked for, and the color is 
to be noticed, as well as the depth of the sulci and superficial evidences 
of softening or sclerosis, morbid growths, and infiltration. The organ may 
be turned over, and the arteries at the base inspected in regard to the 
existence of anomalies, aneurisms, degeneration, tbrombosis, or embolism. 
The fissure of Sylvius may be next examined, and the middle cerebral artery 
traced by sections. As to the method of making cuttings of the brain, 
we may, perhaps, find resort to the horizontal section of Flechsig, espe- 
cially when the patient has presented before death symptoms indicative 
of degeneration of the internal capsule. We are enabled to carefully 
compare by this means the relations of the gray nuclei and the peduncular 
fibres. The cranial nerve-trunks are to be carefully noticed, and if any 
suspicious appearance is observed, a section may be removed for micro- 
scopical examination. The crura and pons are to be examined carefully 
for softening, secondary degeneration, extravasations and the like, and 
the appearance of the basal parts of the hemispheres next noticed. The 
brain-substance may be inspected, in other ways by cutting through the cor- 
pus callosum, and turning each hemisphere gently back, or by slicing off 
the brain-substance with a broad sharp knife previously dipped in water or 
alcohol, so that the white matter may be examined at different levels, as 
recommended above. The condition of the ventricles should be noticed 
as to the effusion of serum or blood, or the condition of the lining mem- 

^ Kemoval en masse, of the brain and its membranous coverings should never be 
attempted; the result of such a procedure being mechanical injury, which reduces 
the organ to a pultaceous mass, rendering it unfit for examination. 



20 INTRODUCTION. 

branes. The parts at the floor of the lateral ventricles deserve special 
study, and the corpora striata should be inspected very attentively, the 
extra-ventricular and intra-ventricular parts being carefully sliced. A 
vertical section just posterior to the fissure of Rolando (Pitre's section) 
may be made. The fulness of the vessels in the deep parts of the 
brain, the existence of patches of softening or induration, and the pres- 
sure of cysts, tumors, or morbid growths should be looked for. It is al- 
ways advisable in cases where aphasia has been a symptom during life, 
to carefully inspect the anterior convolutions, particularly the third 
frontal, which is the generally acknowledged seat of the lesion, and we 
may do this examining at the same time the appearance in the fissure of 
Sylvius, and carefully slicing that portion of the brain anteriorly, and 
laterally to the corpus striatum of the left side. 

It is hardly necessary to allude to the importance of carefully exam- 
ining the medulla and the roots of the various cranial nerves, the pyrami- 
dal decussation, and the cerebellum, and for this purpose it is advisable 
to remove such parts as are wanted for subsequent microscopical exami- 
nation. The cord must be examined critically in cases of spinal disease, 
and the same directions are given for its inspection. Suspected portions 
may be cut out and laid aside, care being taken to secure as much of the 
external roots as possible. In special cases nerve trunks or peripheral 
nerves may be exsected for future examination, and in cases presenting 
iLiuscular atrophy and degeneration it is well to ascertain the morbid 
changes in the muscles. If we desire to use the microscope it is gener- 
ally necessary to harden the tissues, although fresh nervous substance 
may be teased apart in glycerine or serum by needles prepared for the 
purpose. If we prefer the first method we may put such masses of the 
brain or cord as we desire to harden into Miiller's fluid, which is prepared 

as follows : — 

R. Potass, bichromat. 50 grammes, 
Sodic sulphate, 20 grammes, 
Water, 1600 grammes : 

Or, what is better, the solution recommended by Prof. J. W. S. Arnold, 
of the Medical Department of the University of the City of New 
York : 

R- Ammon. bichromat. 11 grammes, 
Methyl alcohol, 320 grammes, 
Water, 640 grammes. 

Care should be taken not to secure specimens which are too large, as 
tlaey do not harden thoroughly, the exterior becoming hard while the in- 
terior is diffluent and useless. They should be left in the solution for a 
month or six weeks, but not till they become granular or cheesy, for then 
it is impossible to make a good section, as the tissue is apt to crumble 
under the knife. At the end of this time, or when the tissue is quite firm, 
it may be removed and placed in a fifty per cent, mixture of alcohol and 
water. The specimen may be examined to test its hardness by making 
sections with a razor from time to time. If a very thin section can be 



MICROSCOPIC EXAMINATION. 21 

made with a moistened razor without parting, adhesion, or crumbling, it 
may be considered to be in fit condition for removal from the hardening 
solution. A solution of bichromate of ammonium, 15 grains to the ounce 
of water, is an excellent hardening solution, in which the specimen may- 
remain until it has been uniformly saturated, and hardening has com- 
menced, and then it is to be removed and placed in a solution of chromic 
acid, two grains to the ounce of water, where it is to remain until hard 
enough for cutting. This is the process recommended by Dieters. The 
specimens may be taken out and kept for use in dilute alcohol till they 
are needed. 

When the hardened tissue is to be examined, it is to be imbedded in pith 
or paraffine, and either placed in a section cutter, or held in the hand. By 
practice, this latter procedure becomes quite easy, and very thin sections 
may be skillfully made. A piece of brain or a length of cord of a convenient 
size is surrounded by elder pith previously prepared to receive it, and bound 
in place by a string, or by a piece of fine copper wire. When moistened, the 
pith swells so that the tissue receives uniform pressure and support. If 
the paraffine process be that employed, the tissue is to be carefully dried 
and placed in a small paper mould which is afterwards filled with melted 
paraffine, this however should not be too hot,^ and care should be taken 
to exclude air-bubbles. When cool and solid the upper part of the paper 
may be torn away, and the specimen is ready for cutting. A flat razor 
is the best instrument of which I know for ordinary work. Its blade 
should be dipped in a saucer containing alcohol placed conveniently by, 
and the face of the section should be moistened from time to time. The 
individual holding the mould firmly between the thumb, forefinger, and 
second finger of the left hand, cuts away a portion of mould and tissue 
so that a level surface is left exposed ; then, with moistened razor, he 
plants the blade, and slowly cuts a thin slice of paraffine and tissue to- 
gether ; this is removed by a camel's hair brush which has been dipped 
in alcohol, and next dropped into a small vessel containing dilute alco- 
hol, and then placed in the staining fluid, which may be the follow- 
ing:— 

R. Carmine (pure), gr. xx, 

Liq. ammoniae, q. s. ut dissolv., 

Glycerinse, 

Aquae, aa ^ij. — M. 

After being allowed to soak for several hours or days, the sections are 
removed and dropped into water slightly acidulated with acetic acid. 
They are now to be placed in absolute alcohol for a short time, and after- 
w^ards in oil of cloves until they become transparent. A perfectly 
clean slide is procured, upon which one of them is placed and a drop (not 
too large) of Canada balsam is next applied. * It is then covered by a thin 

^ I have recently used metallic bottle caps, which may be easily procured. When 
the paraffine is cool the metal may be stripped off. 



22 INTRODUCTION. 

glass cover, care being taken to exclude air-bubbles. Various prepara- 
tions are used to stain nervous tissue ; for instance, a solution of chloride 
of gold will stain the nerve fibres, and render them more distinct ; hsema- 
toxylin and osmic acid are also used, and the black analin process of 
Herbert Major^ produces the most beautiful results. These manipulations, 
however, are out of place here, and I would refer the reader to any one 
of the excellent text-books that have appeared during the past few years 
for more explicit directions. 

It is often necessary to make sections in all possible directions and posi- 
tions, and to do this properly the microscopist must not only have practice 
but patience and care. It is advisable to procure at least two objectives, 
one for coarse appearances, and the other for minute changes, and I would 
suggest that these should be an "inch " and a " quarter inch." 

INSTRUMENTS USED FOR THE DIAGNOSIS OF NERVOUS DISEASE. 

It is essential that we should possess certain instruments which shall 
be more valuable and exact than our Unaided senses, so that we may not 
Fig. 1. only make reliable investigations, but compare from time to 
time such variations as may occur in the patient's condition. 

Those I propose to describe are intended for examinations of tem- 
perature and sensory changes, and for the detection of altered 
motility. 

The Thermometer. — There are several instruments made for 
the purpose of determining variations in temperature, and though 
some are of extreme delicacy, I do not think it will be worth 
while to recommend them, as they are bulky and troublesome, 
and are better adapted for experimental purposes than actual 
clinical use, and among these is Lombard's instrument. 

In Dr. Seguin's surface thermometer we possess an admirable 
little instrument for testing the surface temperature. It has an 
expanded base, and may be applied to the surface of the body, 
taking care to cover the top by a perforated piece of thin rubber 
or leather. A coat or two of shellac varnish to the upper part 
of the bulb will answer the same purpose, viz., that of prevent- 
ing the mercury from being affected by the temperature of the 
room. For the determination of deep temperature we may 
avail ourselves of any of the good self-registering instruments. 
Two surface thermometers should be used, one on the sound, 
and the other on the affected side of the body, and the deep 
temperature maybe taken at the same time for comparison. A 
new form of surface thermometer has recently been made in 
England. The glass tube is spirally coiled upon itself and 
enclosed in a circular box. This form has the merit of being 
unaffected by other than the body temperature. 



West Riding Reports, vol. v. 



CEREBRAL THERMOMETRY. 23 

Within the past two or three years a great deal of interest has been 
excited by the remarkable investigations of Broca, who found that it was 
possible to detect deep changes of temperature in the cerebral organs by 
means of surface thermometers applied to the exterior of the cranium ^ 
Broca's observations were confirmed by those of ^ Dr. Landon Carter Gray, 
of Brooklyn, N. Y., and by ^Maragliano and Seppilli, two Italian experi- 
menters. Albers of Bonn was undoubtedly the first person (1861) to 
suggest cerebral thermometry ; but Broca's work was the first undertaken 
in a systematic and fruitful manner. 

By the use of six or more thermometers applied to the head at various 
points, with every allowance for external disturbing agencies and sources 
of error, it is found that the central temperature undergoes various modi- 
fications, amounting sometimes even to several degrees ; and Gray was 
enabled to diagnose and localize the existence of a cerebral tumor by this 
diagnostic means. The thermometers should be those known as Seguin's, 
or, better still, of the form modified by Dr. Gray. They should be tempered 
perfectly, and so constructed that ordinary pressure upon the bulb shall 
cause no rise in the column of mercury. 

Apropersystemof straps (Fig. 2), -p- 9 

such as has been devised by Dr. 
Gray, or a cap of gum-rubber, with 
perforations, enables us to apply 
the thermometers upon both sides 
of the head, over the points we 
desire to examine. Dr. Gray has 
adopted the names Frontal, Parietal, 
and Occipital — stations relating to 
the positions indicated by the names 
to designate the places over which 

the tests are to be made. A ther- Gray's system of Head straps. 

mometer is to applied (after the 

index column is shaken down) to these spots for a period at least 
of twenty minutes, and then the figures are read without remov- 
ing the instruments. When a spot with increased temperature is 
found, the other thermometers are to be grouped about the suspected 
locality. Kepeated tests show more or less sameness in the readings, so 
that it is possible to determine that a very limited portion of the brain is 
the seat of morbid action. In one case Gray was enabled to diagnose a 
tumor before death. 



1 Pr ogres Medical, 1877, quoted by Gray. 

^N. Y. Med. Journal, August, 1878, p.'l31. 

^ Ee vista Sperimentale di Freniatria e di Medicina Legale. 

^ The adjustment of these straps should be made so tliat those passing over the head 
should go in front and behind the fissure of Kolando which divides the important mo- 
tor tracts. Gray measures from the fronto-nasal fissure, and fixes the location of the 
fissure as 6^ inches posterior to this point. 




24 INTRODUCTION. 

^Dr. Gray thus details the observations he made : — 

"The patient was a female, aged thirty-four. There was present a 
typical ' choked disk/ marked pain in the temple and brow, becoming 
unbearable in paroxysms, nausea, vomiting, ptosis, paralysis of the ocu- 
lar muscle. The first paroxysm of pain came on January 21st. The 
bodily temperature ranged near the normal. Upon these symptoms a 
diagnosis of intra-cranial tumor was made, probably situated at the base. 
Placing my thermometers upon the head, I ascertained the temperature 
at the different stations to be as follows : 

Left. Eight. 

Frontal, ....... 96.75° 98.33° 

Parietal, 95° 99.75° 

Occipital, 96.75° 100.50° 

The average of the two sides, if calculated, will be found to be 96.16° 
on the left, on the right 99.52°, the average for the whole head being 
97.84°. 

The rise above the normal averages is startlingly apparent. At the 
Left Frontal Station it was 2.39°; at the Left Parietal, 56.0°; at the Left 
Occipital, 4.09°; at the Right Frontal, 5.12°; at the Right Parietal, 
6.16°; at the Right Occipital, 8.56°; while the average of the leftside 
had mounted above the normal 2.33°, the right side 6.66, and the average 
of the whole head 4.33° ! 

This particular observation was taken as I was at the outset of my 
study of the subject, and was made with my first set of thermometers, 
which, as I have already stated, were defective. I have satisfied myself, 
however, that the defect amounted to but a little over one degree. If, 
therefore, from these figures one and a half degree be deducted, all fear 
of error may be dismissed ; and yet the increase is unmistakable. About 
this date (March 4th), I wrote Dr. Rockwell : " I shall certainly expect 
to see inflammatory changes from the base of the fissure of Sylvius back- 
ward along the occipital lobe, as well as that these changes shall be spread 
around the base of the fissure." The patient died March 16th. * 
^ ^ ^ * ^ " The meninges were found 

apparently normal, with the exception of a slight congestion. At the 
base of the brain the membranes and skull were to all appearances 
healthy. But a soft, jelly-like tumor, the size of a hazel-nut, was found 
between the horizontal or posterior branch of the fissure of Sylvius and 
the first temporal fissure, while the whole of the right occipital lobe was 
converted into a colloid, extremely vascular mass, which gave way under 
examination, this degeneration also extending anteriorly to the tumor as 
far as the fissure of Sylvius. There was no apparent disease except 
at these points. Upon microscopical examination, I ascertained the 
tumor to be a typical glioma, thickly strewn with small extravasations of 
blood." 

Dr. Chas. K. Mills'^ has reported an interesting case of tumor of the 

1 Loc. cit. 2 piiii, Med. Times, Jan. 18, 1879. 



^STHESIOMETER. 



25 



brain, involving portions of the first and second frontal convolutions, in 
which he found that the temperature obtained over the middle frontal 
station averaged 1.50° above that of the other stations. 

The evidence collected by the few observers already mentioned shows 
the normal average temperature to be about as follows at the stations 
designated : 





GRAY. 


MARAGLIANO AND 
SEPPILLI. 


BROCA. 


K. Frontal .... 
L. '' .... 
R. Parietal .... 


. . . 93.71° . . . 
. . . 94.36° . . . 
. . . 93 59 . . . . 


.... 97.07 .... 
.... 97.16 .... 

. . 97 07 ... 


. . . 95.39 

. . . 95.79 
. . . 92 84 


L. " .... 


... 94 44 ... 


. . . .97 12 . . . 


. . . 91.49 


U. Occipital .... 
L. " .... 


. . . 91.94 .... 
. . . 92.66° . . . 


. . . .96.71. . . . 
. . . .96.81. . . . 


. . . 92.66 



N. B. The experiments of Gray and Broca were made during cool weather. 

Gray found the average tempera ture on the left side of the head to be 
93.83° ; right, 92.92°. The average temperature of the whole head, ex- 
clusive of the vertex, 93.51°. Average temperature of motor region of 
vertex, 91.67°. His conclusions may be summed up as follows : 

" If there be an alteration of temperature at any of the lateral stations 
of more than one and a half degree above or below the average tempera- 
ture of such station, this fact will justify a suspicion of abnormal change 
at that point. 

"If there be an alteration of temperature at any of the lateral stations 
of more than two degrees above or below the average of such station, this 
fact will constitute strong evidence of the existence at this station of ab- 
normal change. 

" In proportion as the alteration of temperature at any individual sta- 
tion is increased or decreased beyond the figures just mentioned, in exact 
proportion will the strength of the evidence be increased as to the exist- 
ence of abnormal change at that station, until, the maximum or mini- 
mum having been passed, the evidence will become almost conclusive. 

" Should it so happen that such elevation of temperature above the 
average should be at any lateral station on the right, causing a rise at 
this point beyond the average temperature at the corresponding station 
on the left, this would strengthen the suspicion or the evidence." 

My own observations have been but few in number, though I trust I 
shall soon be able to add to Dr. Gray's valuable collection of facts. 

In one case of undoubted cerebral tumor under my charge there is a 
rise of temperature of three degrees, which does not even vary a degree 
though I have made over thirty examinations under all sorts of circum- 
stances. In one case of chronic cerebral meningitis, there was a general 
rise of cranial temperature, which was highest at the vertex, however. 

The JEsTHESiOMETER was first suggested by Sieveking, and has since 
been modified by different individuals. We have several different varie- 



26 



INTRODUCTION. 



ties to choose from, but no one is better than the original instrument of 
Sieveking, which is also used and recommended by Brown-Sequard. It 
is made of brass or steel, and very closely resembles a shoemaker's mea- 

Fig. 3. 



!l|ll»"lllllllllllllllll 




Sieveking's ^sthesiometer. 



sure. The movable slide and permanent arms at the end are sharp- 
pointed. The bar upon which the^ free slide moves is ruled in centi- 
meters. 

The other sesthesiometers are mostly shaped like dividers, and are open to 
the objection that the points are liable to be unconsciously approximated 
when the instrument is removed, so that the result of investigation is 
somewhat unreliable. Carrol's sesthesiometer has one advantage. The 
points are bifurcated, one arm ending in a bulb, while the other is sharp, 
so that analgesia as well as anaesthesia may be tested. 



^STHESIOMETER. 27 

Dr. E. C. Seguin has made a very decided improvement upon the 
original instrument of Sieveking. He has had it constructed of alumi- 
num, and of a smaller size, so that it is light and small, and may be 
easily carried in the pocket-case. 

The principle upon which the sesthesio meter is constructed is the fol- 
lowing : The normal receptivity of tactile impressions enables the subject 
to distinguish two points which are brought simultaneously in contact 
with the skin. This susceptibility varies greatly in different regions in 
proportion to the delicacy of the tactile sensation located therein. If 
there be loss of sensation as an accompaniment or result of nervous dis- 
ease, of course the distance between them will have to be increased be- 
fore the points will be felt as two. In hypersesthesia they may be much 
more nearly approximated and distinguished as two than in the anaesthe- 
tic state. 

The average distance at which the two points of the instrument can be 
felt in the normal state are as follows : — 

Point of tongue ^ line 

Eed surface of lips 2 lines 

Palmar surface of third finger 1 line 

Tip of nose 3 lines 

Metacarpal bone of thumb 4 " 

Skin of cheek 5 " 

Mucous membrane of hard palate 6 " 

Dorsal surface of first finger 7 " 

Dorsum of hand over heads of metacarpal bones 8 " 

Mucous membrane of gums 9 " 

Lower part of forehead 10 " 

Lower part of occiput 12 " 

Back of hand 14 " 

Neck under lower jaw 15 " 

Vertex 15 " 

Skin oyer the patella 16 " 

Skin over the sacrum 18 '' 

Skin over the sternum 20 '' 

Skin over cervical vertebroe 24 '' 

Skin over middle of back 30 " 

Skin over middle of the arm 30 " 

Skin over middle of the leg 30 *' 

Certain precautions must be taken when using the sesthesiometer, or 
else our examination will be unsatisfactory in the extreme ; we must not 
depend in all cases upon the patient's statement, but exercise tact in get- 
ting from him satisfactory answers, and not guesses. There seems to be 
in some individuals a discouraging stupidity which prompts them, in an- 
swer to the question, " How many points do you feel ? " to oftentimes re- 
ply " Three," when they know that the instrument has but two points. 
It is of the greatest importance that the patient's eyes should be covered 
or that he should close them, as he will unconsciously look at the instru- 
ment during its application. It is also of moment that the points should 
be fairly and at the same time applied to the skin, one not being pressed 



28 



INTRODUCTION. 



more than the other, and finally, it may be stated that they should not be 
applied at any place where the clothing has rubbed or chafed the surface. 

Fig. 4. 




Diagram for making Records. — Roman numerals show anaesthetic indications, the 
others normal sensibility. 

Since the appearance of the first edition of this book Dr. Hughes, of 
St. Louis, has devised a very convenient instrument, a new feature being 
an ingenious scale of measurements upon its bar, with a standard for 
reference. 

Various tests of sensibility are simpler than those of the kind I have 
described. For gross tests the finger tips of the examiner may be applied 
and separated like compass arms. Shape and pressure may be deter- 
mined by the application of various-sized bodies, weights, or coins, the 
subject's eyes being meanwhile bandaged. 

The Dynamometer. — Various forms have been devised, that in general 
use being invented by Burq and introduced by Mathieu. It consists of an 
elliptical spring, which, when compressed in the hand, registers upon an in- 
dex the force exerted. When the needle is forced ahead it remains at the 
point it had reached when pressure was remitted, and the spring expands. 
Its disadvantage lies in the inequality of pressure made at different times, 
the bulky character of the apparatus, and its inadaptability to other uses. 



THE DYNAMOMETER. 

Fig. 5. 



29 




Mathieu's Dynamometer. 



Having recognized the necessity for an instrument that would meet the 
therapeutical requirements not possessed by those of Mathieu or Du- 
chenne, I have devised that figured in the appended illustration. It con- 
sists of a long glass tube (2) which dips into a small bottle filled with 
mercury. In connection with a bent brass pipe (3) is a rubber tube 
which terminates in a closed rubber bulb (5 \ When this bulb is com- 
pressed the mercury is forced up in the glass tube, the end of which is 
closed. Attached to the tube is a scale (1) registered on one side in pounds, 
and on the other by marks separated by regular intervals for the purpose 
of making comparative estimates. As fifteen pounds' pressure to the 
square inch is required to compress a given body of air into one-half its 
original space, of course a force of fifteen pounds' pressure brought to 
bear upon the bulb would be required to press the column of mercury 
halfway up the scale. The advantages of this apparatus are the follow- 
ing:— 

1. I^ts simplicity. 

2. The adaj)tability.of the rubber bulb to receive pressure exerted by 
all the flexors of the hand. Mathieu's spring is only acted upon by a limited 
number ; at the same time, therefore, the test is not a true one. 

3. The action of the muscles is the same at different times. The same 
group of muscles always being brought into play, accurate comparative tests 
may be made from day to day. 

4. The part receiving the pressure is of a convenient shape to be used 
by persons with either small or large hands. 

5. It is accurate and always gives reliable indication of the pressure 
brought to bear. 

Dr. Birdsall of this city has recently invented a most ingenious foot 
dynamometer for testing the strength of the lower extremities. 

The dynamometer is at best an instrument of questionable value, as are 
others requiring an effort upon the part of the patient. In rough tests of 
power it is useful, but in accurate case-taking, very little importance can 
be attached to the detailing of small variations as recorded upon the dial 
or scale of any dynamometer. * 

I have combined the rubber bulb with the drum of Marey, and am 
enabled to obtain gross variations with tolerable accuracy. The drum has 



30 



INTKODUCTION. 



two pipes, one of which is connected with the rubber bulb, while another 
is attached to the lower end of an open glass tube. The bulb-drum cavity 

Fig. 6. 




The Author's Dynamometer. 

and a part of the tube are filled with colored fluid, so that the fluid in the 
latter reaches a mark at about the middle of its length. The patient grasps 
the bulb and makes enough pressure to force the fluid in this tube to a mark 
slightly above the other. The sustained voluntary effort required to keep 
the fluid at this point necessitates some delicacy of muscular co-ordination, 
and should this be impaired there will be expansion of the drum-head and 
consequently irregular tracings upon the cylinder of the registering appa- 
ratus. This cylinder should be covered by a piece of smoked paper, and 
the stylet placed in apposition thereto. 

In alcoholic tremor, commencing sclerosis, and the metallic tremors, we 
may obtain very beautiful tracings. 

The Ophthalmoscope. — The parts composing the ordinary "ophthal- 
moscope are the following: A concave mirror perforated at its centre, a 
series of lenses by which the refraction in the subject's or observer's eye 



THE OPHTHALMOSCOPE, 



31 



may be corrected, and a bi-convex lens The three forms in common use 
are those of Liebreich, Loring, and Knapp. The two latter are essentially 
alike in construction, and the first is quite primitive, usually of bad con- 
struction, and quite unreliable. 

Fig. 7. 




Loring's Ophthalmoscope. 

In the examination with this instrument great care should be taken by 
the observer to determine whether he or his subject possesses errors of re- 
fraction, and if so, to correct them with the proper lenses. In the modern 
ophthalmoscope a number of lenses are held in a revolving disk behind 
the mirror. 

For more specific directions the reader is referred to Dr. Loring's ad- 
mirable little work.^ 

To examine the eyes of a patient properly, the observer may follow the 
concise directions laid down by Hutchinson.^ 

" Having placed the patient's head in such a manner that the light (a 
lamp, candle, or gas-light) is on a level with his temple, and slightly be- 



^ Determination of Errors of Refraction with the Ophthalmoscope. E. G. Loring. 
Wm. Wood & Co., N. Y. 
'^ Jonathan Hutchinson. Clinical Reports of London Hospital, 1867 — 8, 



p. 182. 



32 INTRODUCTION. 

hind it, and his face, as a consequence, in shadow, the observer sits in 
front and applies the ophthalmoscope mirror to his own eye. He should 
keep both eyes open that he may see where the light falls, and then move 
the mirror until the light falls full on the pupil of his patient. In a mo- 
ment he will perceive the first fact which this instrument reveals, that the 
fundus is not black, as it has always appeared to be before, but that it is 
of a brilliant fire-red. He will, however, see nothing of the fundus dis- 
tinctly, only a general red reflex. Now at this point the student must 
stop awhile and use his mirror, to inspect, first, the transparency of the 
cornea, and, next, that of the lens and vitreous, and to do this he must 
make the patient move his eye in various directions. After a little prac- 
tice he will be able to manage his light well, and to throw it with preci- 
sion wherever he may wish, and to keep it steadily on any given part. At 
a first lesson he may even, with advantage, practise for a while by illumi- 
nating the second button of the patient's waistcoat. Tact in directing the 
light having been obtained, we may now proceed further. Instruct the 
patient to look, not full in your face, but over one shoulder ; if you are 
inspecting his right eye, over your left shoulder. You will, when he does 
this, notice at once that the tint of the light reflected from his fundus is 
changed, that it is no longer fire-red, but canary yellow. The reason of 
this is that a different part of the fundus is exposed to view, that, namely, 
of the optic disk itself, which is much lighter in color than the rest. The 
area of yellow is very large — occupies, indeed, the whole of the field, 
while we know that the disk itself is very small. This proves that the 
objects thus indistinctly seen are immensely magnified. Magnified by 
what? By the patient's own eye, which, as we have said, is equivalent to 
a lens of one inch focus. 

" Hitherto we have seen nothing distinctly, but if the observer now 
brings his head very close to his patient's face, he will be able with more 
or less facility to observe the details at the bottom of the eye, the trunks 
of vessels of the retina, the optic disk, etc , etc. All these will be seen 
very large indeed, being still magnified by the patient's eye. What he 
sees now is equivalent to type looked at through a one-inch lens, placed 
exactly one inch in front of it." 

Without entering into an extended discussion as to tho value of this 

Note. — Dr. Loring says, in concluding an admirable paper : " By the experiments 
considered in the foregoing remarks two alternatives are forcibly presented to our 
mind: either that the circulation of the eye is not a reflex of the circuiation of the 
brain, though derived directly from it ; and thus agents which affect profoundly the 
one have little or no influence on the other; or, if the retinal circulation is a reflex 
of the cerebral, it follows that the influence exerted on the circulation of the brain by 
agents at our command, remedial or otherwise, is very much less than heretofore 
supposed. 

" I cannot but think that the former alternative is the more rational, and from that 
very independence of the two circulations there is reason to fear, so far as functional, 
and especially mental diseases, are concerned, that there never will be, any more 
than there now is, any art to read the mind's construction in the eye." 



THE PERCUSSIOX HAMMER. 



33 




instrument as a means of diagnosis, it will be well to state frankly that I 
do not believe that it possesses any positive value in the diagnosis of brain 
disease, except where the condition of the fundus is the result of an organic 
disease of the brain or cord, or when it is possible to 
connect such disorders with errors in refraction. Fig. 8. 

In m.aking this statement I shall, perhaps, find 
many opponents, but I nevertheless have many 
powerful allies. 

Bouchut,-^ Panas,^ Albutt,^ Bull, and others have 
written extensively, and have furnished a large 
number of clinical reports of ophthalmoscopic 
changes co-existent with cerebral tumors, menin- 
gitis, softening, effusion, cerebral hemorrhage, gen- 
eral paralysis, locomotor ataxia, and other forms 
of sclerosis, epilepsy, and the syphilitic and ursemic 
neuroses. Hutchinson,* of Philadelphia, in an 
admirable article, gives many of these cases, and 
shows the real value of the ophthalmoscope, espe- 
cially when an examination of the fundus reveals 
choked disk and optic neuritis, but I will speak 
more fully in regard to this subject when Ave come 
to the discussion of special diseases. 

My friend Dr. Buzzard, of London, demonstra- 
ted to me at the National Hospital for the Epi- 
leptic and Paralyzed, a useful application of the 
ophthalmoscope, for the purpose of testing the sen- 
sibility of the iris. The patient sits in a dimly- 
lighted room and looks at some object at a distance, 
so that the pupil is not contracted in accommoda- 
tion. A pencil of light is then thrown upon the 
eye-ball to one side of the pupil, and gradually 
changed in direction, so that the iris is suddenly 
stimulated. Erb prefers for this test the use of arti- 
ficial lipjht concentrated bv a convex lens. 



11 

m 

^ i 

i 



& 



Percussion Hammer. 



The Percussion Hammer — For the purpose of 
rapping the patellar or other tendons, the ordi- 
nary percussion hammer with a rubber head, such 
as is ordinarily used by medical men in chest 
examinations, has been adopted. 

One with a flexible whalebone handle is the best. 
The patient seats himself with both feet upon the ground, with bared 

1 Du Diagnostic des Maladies du Systeme ^N'erveux par rOphthalmoscope. Paris, 
1876. 

2 La France Medicale, Feb. 26, 1876. 

■^Med. Times and Gaz., vol. i., p. 495, and seq. 
*Phil. Med. Times, May 8, 1875. 

3 



34 



INTRODUCTION, 



legs and a smart blow is then struck just below tbe patella, with the effect 
of producing the " tendon reflex " movement. A sharp contraction of 
the quadriceps fem oris generally occurs in the healthy person, and a more or 

less violent extension of the leg follows. This 
method of procedure may be resorted to, or 
the patient may cross his legs, and the ex- 
aminer may tap the tendon of the depen- 
dent knee. 

The position of the limb should never be 
constrained or uncomfortable, and there 
must be no voluntary contraction of the 
muscle upon the part' of the patient. In 
cases where there is unusual excitability 
of the "tendon reflex" the blow may be 
struck upon the tibia. In fat persons the 
patient's leg may be supported upon the 
arm of the examiner, as figured in the an- 
nexed illustration. This subject will iu 
another part of this work be alluded to 
more fully. (See "Diseases of the lateral 
columns, etc.") 




Producing the " tendon reflex " 
movement. (Gower.) 



APPARATUS FOR THE TREATMENT OF NERVOUS 

DISEASE. 

Electrical. — Two forms of apparatus are required — one for the pro- 
duction of galvanic, the other for the induced or Faradic current — as 
well as the necessary electrodes. 

As we know, the galvanic current is derived directly from a battery 
or pile, the first consisting of two elements, which are contained in a 
vessel filled with some exciting solution, and the latter of plates of metal 
placed one above the other, and separated by disks of felt or paper 
moistened with a solution of salt or acid. This last apparatus is rarely 
used. 

One vessel or cell of the, form I have first described constitutes a 
simple battery, and two or more, with the poles alternately connected, a 
compound battery. 

Two qualities of electric force are generated by a ba^ttery of this kind : 
1. Quantity: 2. Intensity. The latter is the characteristic which makes 
it valuable as a means for the production of muscular contraction and 
nerve stimulation. 

The Faradic current is derived from a galvanic cell primarily, and is 
developed by its passage through a coil of wire wound about a central 
core or bundle. Two currents are induced therein : one the primary 
induced, the other the secondary induced. The first is less coarse and 
vi 3lent in its effects than the other. 

For a more extended description of electro-physics, physiology, and 



RUBBER MUSCLES, ETC. 35 

therapeutics, I would refer the reader to any of the works mentioned at 
the foot of this page. ^ 

For the production of the galvanic current, we may avail ourselves of 
either one of the permanent batteries ; the cells of which may be set up 
in the cellar, and the wires carried to a proper board in the office, 
containing apparatus for their selection ; or we may use the ordinary 
portable galvanic battery, many styles of which are made. 

I have given the Leclanche battery a fair trial, and now do not 
recommend it, as it is dirty, inconstant, and rapidly loses power. The 
'' magazine battery " of Chester, in which the peroxide of lead is substi- 
tuted for the black oxide of manganese in the porous cell, is much better. 
The old Daniel's cell is, I am convinced, the best of all, and whether in 
the form of the Siemens and Halske, or Hill modification, is all that can 
be desired. 

The table board of Fleming of Philadelphia, or the arrangement 
known as the " cabinet battery," which is made by the Galvano-Faradic 
Company of New York, is admirable for office use. 

The Faradic instrument should be provided with an attachment for 
the slow or rapid interruption of the current, an addition to the ordi- 
nary battery, which will be found of immense advantage in certain forms 
of paralysis. The instruments of the two firms I have mentioned, be- 
sides those of Drescher and Kidder, are all good. 

Two or three cotton-cloth covered electrodes of different sizes, or fiat 
sponges with rubber backs, with fine wire pole cords instead of the flimsy 
gold-thread connections in present use, which oxidize and break, will be 
needed, as well as a bundle of fine wires held in a handle, which is 
known as an electric brush. Static electricity has lately received, some 
attention. Beyond its moral effect upon the patient, especially if there 
be hysteria, I do not believe that it possesses any advantages over the 
chemical currents. 

KuBBER Muscles, etc. — Dr. Van Bibber, of Baltimore, has devised 
a very useful apparatus for the treatment, especially of lead paralysis. 
It consists of a strap for the hand or other part which needs support, 
and one for a point of attachment of the muscle. When properly 

Either of these works will be found practically useful to the student : — 
Tibbit's Handbook of Medical Electricity. 
"Eeynolds' Clinical Uses of Electricity. 
Althaus's Electricity, Theoretical and Practical. 
Poore : A Text Book of Electricity, etc. 
Lincoln's Electro-Therapeutics. 

Beard and Kockwell's Medical and Surgical Electricity. 
Hamilton's Clinical Electro-Therapeutics. 
Duchenne's de 1' Electrisation localise, 1872. 
Onimus et Legros, Traite D'Electricite Med. 
Benedikt Electrotherapie, 1874-5. 
Ziemssen, Die Electricitat in der Med., 1872. 
Besides, the works of Kosenthal, Erb, Meyer, Eulenburg, and others. 



36 



INTRODUCTION. 



applied, the rubber pipe, which takes the place of the paralyzed 
muscle, raises the hand, so that the strain upon the enfeebled muscle is 
relieved. Dr. Van Bibber has also used court plaster for the treatment 
of ptosis and other minor paralysis. 

The Hypodermic Syringe, Ether Spray Apparatus, and Spinal 
and Cranial Ice Bags, should be procured by every physician who has 
occasion to treat this class of diseases. 

Cauteries. — Until a few months ago the old forms of cautery were 
used almost exclusively. These are of iron, and are sometimes platina 
covered. When needed, they are heated in the flame of a Bunsen 
burner, Russian blast lamp, or some such contrivance, but lose their heat 
very rapidly, and generally assume a dead red color when applied. The 
glass rods, heated in a like manner, though somewhat more convenient, 
become very quickly cool. 

Dr. J. J. Putnam, of Boston, exhibited at a meeting of the American 



Fig. 10. 




The Author's Gas Cautery. 



Neurological Association the first gas cautery seen in this country, 
though Alex. Bruce years ago invented a cautery of this kind. It 



CAUTERIES. 37 

was constructed in such a manner that the jet of an ordinary gas blow pipe 
was directed upon a cup of platinum. Its advantages over the older 
variety were manifold, but it possessed faults I have tried to remedy in 
a modification. 

The advantages of this instrument are the following : — 

1. The jet which prevents all hissing or noise, and still produces a very 
powerful blast. 

2. The apron of wire gauze, which prevents the return of flame, thus 
obviating the danger of burning parts that we do not wish to affect. 

3. The large bag, which acts as a reservoir, so that the operator need 
not use the rubber bulb nor watch the burner after it is filled. 

4. The hook, which enables him to suspend the bag and tubing from 
his person, thus removing all drag. 

The general advantages of this form of cautery are important. A 
uniform heat may be kept up for hours with very little exertion. The 
furnace, which is not only inconvenient, dirty, and alarming to timid 
people, but is a slow method, is done away with. In less than a minute 
the platinum dome can be heated to whiteness. 

The cauteries of Pacquelin and Guerard, of Paris, are both good. In 
them the vapor of benzine (which should be impure) is forced with air 
upon a piece of hot platinum. These are excellent substitutes for the 
cautery I have just described, especially in the country, where there is no 
gas. Messrs. Stohlman, Pfarre & Co. have constructed for me an appara- 
tus which consists of the cautery, handle, and a hard rubber receptacle 
containing charpie which is to be saturated with benzine. There is no 
danger of explosions such as exist when we use the ordinary bottle that 
forms a part of the French instrument. 

It has been recommended that the spinal ether spray be used to deaden 
pain ; but not only is there danger of an explosion when this procedure 
is tried, but it seems to me that the very object of the operation, revul- 
sion, is not accomplished, as the peripheral filaments are of necessity be- 
numbed. 



38 DISEASES OF THE CEREBRAL MENINGES. 



CHAPTER I. 

DISEASES OF THE CEREBRAL MENINGES. 

All of the investing membranes of the brain may be the seat of in- 
flammatory action, but it is almost impossible in certain instances to make 
distinctions between inflammation of the arachnoid and pia mater, though 
this has been attempted by Parent-Duchatelet, Lallemand, and others. 
We will, therefore, have to content ourselves with a division founded upon 
the duration, intensity, and coexisting diseases of the general system, and 
limit our regional diagnoses to forms which may be called meningitis of 
the convexity and meningitis of the base. 

In respect to certain circumstances which modify the appearance of the 
disease we may divide its varieties as follows : — 

Cerebral pachymeningitis, -5 pi. '• 

(Inflammation of the dura mater,) / ^, . ' . , , 

V Chronic, with hsematoma. 

C Basilar, 

Acute cerebral meningitis, ■) Of the convexity, 



( 



Granular. 



Chronic cerebral meningitis. 



PACHYMENINGITIS (INFLAMMATION OF THE DURA). 

Two forms of pachymeningitis are to be met with, one of which is acute 
and is the direct result of injury or disease of the cranial bones, and is 
generally fatal in a short time ; and the other, of a chronic nature, which 
may either remain after injury, or arise from some intracranial cause, or 
perhaps be the result of general disease, or old age. 

ACUTE PACHYMENINGITIS. 

Symptoms. — After the traumatism, or when the external disease 
has invaded the intracranial cavity, the first symptom is usually severe and 
localized pain, which finally extends w^ith the inflammation, and becomes 
dififused over the entire head. 

Rigors, alternating with elevation of temperature, which may sometimes 
attain 105° or 106° F., head pain and occasionally spasms of the arms or 
legs, are ordinary symptoms ; and if the condition be a very acute one, 
there may be general convulsions, or perhaps a partial paralysis, which 
is unilateral. 



ACUTE PACHYMEXIXGITIS. 39 

Delirium usually supervenes in from three days to a week, and coma 
ends the disease, should an effusion of blood take place, and this is a com- 
mon termination. 

The pulse during the first two or three days varies from 60 to 70, while 
towards the end it becomes much more frequent and very full. During 
the invasion, and after the disease is fully established, especially if the 
inflammation extends to the base, the head may be drawn backwards and 
downwards. 

RamskilP has called attention to the hyper-sensitiveness of the cornea, 
and I have been often impressed by another symptom, viz., the redness of 
the conjunctiva and the constant tendency to lachrymation. Vomiting 
very commonly takes place, and is always quite a suggestive symptom of 
meningeal trouble. When the disease follows otitis its onset is not so sud- 
den as when it is the result of injury, but a train of symptoms of gradual 
appearance marks the extension of the morbid process step by step, 
though in some instances rigor with sudden coma may be the first indica- 
tion of mischief. This is in most cases the purulent form. Cases of the 
idiopathic variety of pachymeningitis are quite rare, although several have 
been reported by Abercrombie and other older writers. One case related 
by the former authority may be worth mentioning. This writer also gives 
six others which originated from middle ear disease or abscesses in other 
bony cavities. These latter cases are not uncommon, if we may accept 
the experience of aurists and surgeons. Abercrombie's" patient, in whom 
the disease was idiopathic, died in fifteen days. The first indication was 
severe pain in the left temple, which continued for two weeks, when a 
"swelling" appeared beneath the left upper eyelid. Four days before her 
death violent convulsions took place, which were preceded by slight 
rigors. The swelling was punctured, and a considerable quantity of pus 
escaped. A probe passed into the opening came in contact with bone, and 
could be inserted for some distance, the end being in contact with the roof of 
the orbit. During previous days her condition had varied to a great degree, 
and at times she seemed to be very comfortable. On the day before her 
death she complained of vertical headache, became semi-comatose, and 
died in this state. Extensive discoloration, thickening, and other changes 
in the dura mater were found with adventitious membrane and pus. In 
a case detailed to me by Drs. White and Asch of this city, there was al- 
ternating paralysis associated with aural disease which affected the ears in 
turn. 

Fizeau^ mentions a case which closely resembled this one, and another 
quoted by Abercrombie, and seen by Prathernon, was also of idiopathic 
origin. Abercrombie's other cases presented common symptoms which were 
traced to assignable causes. Dr. Clark ^ has presented five cases of the 

^ Eussell Reynolds' System of Medicine, vol. ii., page 325. 

2 Abercrombie on the Brain, page 21. 

3 Journal de Medicine, tom. ii., Xew Series, page 523. 
* Transactions ^ew York Pathological Society, 1876. 



40 DISEASES OF THE CEKEBEAL MENINGES. 

acute form, due to otitis. Dr. Bauduy another which followed scarlet 
fever, and many of the same kind may be found mentioned by other 
authorities. 

CHRONIC PACHYMENINGITIS. 

A far more interesting class of cases are those which have lasted for 
some time, and have invaded the underlying membranes, ending in in- 
volvement of the cortex cerebri. The following is a fair example : — 

Symptoms. — John McM., age 30, of temperate habits. The patient 
was a young man of the laboring class, and was employed in a machine- 
shop at the time of the accident. Three years ago, while turning a piece 
of metal, it caught upon the end of his turning tool and flew out of the 
lathe (which was driven by steam-power), striking his head, and cutting a 
scalp wound over the upper part of the right parietal bone. He fell un- 
conscious, and was carried to his home, remaining in the same state for 
about eight hours. After this he recovered slowly, was delirious, and evi- 
dently had had convulsions. From this period to the time when I saw him 
his history was not very clear, but he had had convulsive paroxysms from 
time to time, and severe headache, which he complained of when he came 
for advice. This pain was limited to the right side of the head, and prin- 
cipally centered at the injured spot. His face was quite puffed and 
swollen, and his eyes were red and watery. Pressure upon the cicatrix 
caused intense pain. His right pupil was slightly enlarged, and he com- 
plained th^t his vision was imperfect. Sleep was disturbed by the pain 
which would often occur in paroxysms of a very intense character. He 
complained that his left arm felt stiff, and that his fingers were cold, but 
I was unable to find any loss of power. He continued in this state for a 
year or more, and when I next saw him his speech had become slow and 
hesitating, and his face wore rather a silly expression. He then com- 
plained of some feebleness of the left arm and leg. The headache had not 
abated, and the convulsions had been much more frequent. His friend 
who came with him stated that his mind had greatly changed, that his be- 
havior was eccentric, and that he had had delusions of various kinds. I 
subsequently lost sight of him. In some features this case resembles one 
of softening. This form of chronic pachymeningitis is much more obscure 
when it is connected with syphilis. There is not only a great dispropor- 
tion between the severity of the symptoms and the extent of the morbid 
process, but symptoms of great variety may be evinced as expressions of 
pachymeningitis of syphilitic origin.^ Lagneau fils^ reports a case in which 
the only symptom was headache, which was most violent at night. Post- 
mortem examination revealed pachymeningitis over the anterior lobes of 
the cerebrum, with bony plates and some sclerosis of the brain -substance. 
There was, in addition, extensive perforation of the ethmoid bone. In- 
stances are related by Gama where the patients had died conscious, 

1 Trans. N. Y. Path. Soc, vol. i., p. 13. 

2 Observation 3, Lagneau, Maladies syphilitiques du Systeme nerveux. Paris, 
1860. 



CHRONIC PACHYMENINGITIS. 41 

and their meninges were found to be decidedly affected, Keyes/ in a 
most complete and exhaustive memoir, presents a number of cases of 
hemiplegia which were the ultimate result of the meniogeal inflamma- 
tion, and calls attention to the pain which precedes the hemiplegia, and 
which is always produced when pressure is made upon the cranium. A 
feature of the hemiplegia is the absence of any loss of consciousness. 

Syphilitic meningitis of this description is very often — I may say almost 
always — symptomatized by a decided failure in the mental powers, which 
begins in fact as soon as the pathological process manifests itself by any 
symptoms at all. I regard this slowness of intellectual action which, by 
the way is general, as almost pathognomonic. In some cases it has been 
almost the only symptom of a pachymeningitis which was not recognized 
until after death. I have, since the appearance of the first edition of 
this book, been called to see several persons, Avho have subsequently died, 
presenting an imperfect hemiplegia — that is to say, a hemiplegia of a 
comparatively light character, but associated with an equally, light coma, 
lasting several days. There was not even laborious breathing, and it was 
possible to rouse the patients. It strikes me that in such cases the pres- 
sure had been quite gradually developed, and the cerebral mass had be- 
come to a degree accustomed to the pressure of the new deposit. ^Bum- 
stead and Taylor thus describe the later stages of syphilitic meningitis : 
"jV general adynamic condition sometimes supervenes in patients affected 
with chronic inflammation of the meninges, which either ends fatally or 
renders them hopelessly bedridden. This weakness may be due to mere 
lack of innervation, or may be complicated by mild ataxic phenomena, 
characterized by unsteady gait and uncertain movements. The dullness 
of intellect by day is succeeded by nocturnal delirium. When lying in 
bed such a patient resembles one in typhoid fever, but there are marked 
points of difference. He is sleepy and dull, and his face is utterly expres- 
sionless. The tip and edges of his tongue are red, but the organ is never, 
unless late in fatal cases, dry, cracked and covered Avith sordes. Anorexia 
and constipation are often quite marked. The pulse ranges from 80 to 
110, is full and not wiry. The temperature may be elevated in the morn- 
ing to 100° F., and at night to 103° or 104° F. If conscious, the patient 
complains of intense headache and weariness. In a week or ten days he 
passes into a condition of complete unconsciousness, perhaps broken by 
brief lucid intervals. The urine and feces are passed involuntarily. If 
not relieved, the condition soon becomes more serious; the temperature 
continues to rise, and the pulse increases in rapidity ; no food is taken, and 
. the stupor merges into fatal coma." The above account is a most graphic 
one, and is a striking picture of a common form of trouble. 

Fournier is inclined to fix the time for the development of syphilitic 



^ Syphilis of the Nervous System. New York, 1870. 

2 The Pathology and Treatment of Venereal Diseases by Bumstead and Taylor, 
4th edition, p. 655. 



42 DISEASES OF THE CEREBRAL MENINGES. 

meningeal symptoms much later than those authors who have met with 
these symptoms in quite recent cases. 

Of my own cases I have never seen syphilitic pachymeningitis before the 
end of the third year, and in most instances at least teix or eight years after 
primary infection. In the case seen with Dr. Asch the development of 
symptoms followed at least fifteen years after the primary disease. It is 
probable, however, that there are cases of acute trouble' with early de- 
velopment of active meningeal inflammation. 

A form of syphilitic pachymeningitis may follow external syphilitic dis- 
ease of the cranial bones. I may illustrate the features of such an attack 
by the following case, reported by Dr. Jas. R. Wood : — 

Marie C, aged 20, was admitted to Bellevue Hospital, on account 
of an eruption of two weeks' duration, which had steadily progressed 
from a few points until it had become general, being most profuse on the 
face, neck, arms, and scalp. 

The eruption presented a distinct coppery hue, and was of two varieties. 
There were three rupitic phlegma on the head, each of which contained a 
little pus, and three or four on the shoulders and back of the same cha- 
racter. The rest were tubercular. 

She stated that, though often exposed, she had never suffered from pri- 
mary syphilis, but that there was a sore on her thigh, near the vulva, 
which appeared two weeks before the eruption. 

On examination, a simple chancre was found at the point complained 
of; there was also a chancre of limited extent in the vagina. Soon after 
admission she w^as observed to have a shuffling gait, and when questioned 
about it stated that her right arm and leg "seemed to be getting weak." 
The treatment consisted in the use of the corrosive chloride of mercury in 
Tluxham's tincture of bark, combined wdth generous diet. 

The eruption on the scalp was left undisturbed. The quantity of pus 
contained in each point was quite small, and it was deemed best to let 
them alone. One of them situated over the parietal bone of the left side 
was something larger than its fellows ; none of them, however, increased 
in size materially. 

There was very little improvement in the eruption, but the hemiplegia 
steadily increased. 

Her appetite became poor, she began to have vomiting, and exhibited 
a cachectic appearance. The bichloride was necessarily discontinued, and 
mercurial vaporization substituted. 

The hemiplegia became more complete, and her mind began to be ob- 
scured. The stupidity gradually deepened into profound coma, in which 
condition she died on the 30th. 

Autopsy. — There was a denudation of the parietal bone of the left side 
of the periosteum, at a point corresponding with the rupitic spot above 
spoken of. 

On removing the calvarium, the dura mater was found inflamed and 
firmly adherent to the skull, just beneath the denuded spot on the parietal 
bone and the eruption. 

A small opening was found communicating between them, perforating 
the cranial walls, and looking very much like a worm-hole. 

The brain at a point corresponding with the inflamed dura mater pre- 
sented a greenish appearance. 



CHRONIC PACHYMENINGITIS. 



43 



There was also an evident fulness and fluctuation. On making an in- 
cision an abscess was discovered which contained about §iij of pus. The 
other organs were healthy. 

As a result of continued congestion we may have a form of pachy- 
meningitis such as follows chronic mania. I have seen this change repeat- 
edly as a secondary condition, but it must be confessed that the other 
meninges were as well afiected. 

Causes. — They may be briefly enumerated as external injury, otitis, 
syphilis, alcoholism, and various acute diseases, among them rheumatism. 

Morbid Anatomy and Pathology. — In the majority of cases 
the inflammation is transmitted to one or more of the important sinuses. 
The most favorable points for the extension of disease of the temporal 
bone are the narrow space between the mastoid cells of this bone and the 
transverse sinus, and that between the cavity of the tympanum and the 
jugular fossa; and the proximity of the auditory meatus to the petrosal 
sinus, and the different canals whicb contain the nerves, to adjacent intra- 
cranial parts. The bony walls between these locations are of a perforated 
and lamellar character, and when attacked by caries are very apt to be 
destroyed. 

Fig. 11. 




Osteoma of Dura Mater (Laneereaux).— a. Bony Plate, b. Perforation. 
Mater, e. Parietal Bone. /. Scalp. 



c. Falx. d. Dura 



If the disease be of a syphilitic nature there is generally a gummatous 
deposit scattered through the tissues, and the under surface of the dura 
mater is often covered by a syphilitic exudation which can rarely be 
mistaken. If it be the result of a traumatism, the membrane is seen to 
be thickened, opalescent, and congested. In old cases it is found to be 
closely adherent to the cranial bones, or it may contain long plates. 

In this form of inflammation the morbid changes may be seen best at 
the convexitv. 



44 DISEASES OF THE CEREBRAL MENINGES. 

Prognosis. — The outlook is invariably bad, for in one variety the 
patient is carried off in a few days, or, should the disease become ohronic, 
its progressive nature must lead us to expect an ultimate implication of 
other parts, and cortical softening or sclerosis and atrophy are probable 
terminations. 

Treatment. — Treatment should be directed in the beginning to the 
cause, and if there be otitis, a free escape of pus should be provided for, 
and counter-irritants, topical applications, and leeches should be em- 
ployed. If the pachymeningitis be attended by much pain, cold to the 
head and free administration of the bromides will be of service. The 
leeches may be applied to the tragus of the ear, or to the mucosas mem- 
brane of the nostril. 

CHRONIC PACHYMENINGITIS WITH HEMATOMA. 

It has been the custom, among certain writers lately, to speak of hsema- 
toma as an inevitable result of pachymeningitis. This, I think, is a mis- 
take, for the production of blood-cysts is not the invariable rule. If, how- 
ever, the thickening of the dura mater is excessive, there may be a gradual 
destructive process, which will be described when we come to speak of the 
morbid anatomy and pathology of the affection. 

The disease may begin as I have already described, and may advance 
to a certain point before the grave symptoms which indicate rupture and 
consequent meningeal hemorrhage are expressed. These may vary in in- 
tensity in proportion to the extent of the effusion, which may be even so 
great as to produce sudden death, but such an early result is exceptional. 
The course of the disease is generally more gradual, and there is at first 
an initial hemorrhage of slight extent, which is followed in a great num- 
ber of cases by two or three others. In some respects this effusion resem- 
bles cerebral hemorrhage in the production of acute symptoms, but they 
are nearly always less profound ; and it is not so frequently followed by 
complete paralysis. 

Symptoms. — The early symptoms of pachymeningitis that I have 
enumerated are those preceding the immediate evidences of the effusion. 
They may be reinforced by loss of memory and stupidity, and after a few 
months there may be a transitory loss of consciousness and incomplete 
hemiplegia which is characterized by much hypersesthesia. 

The phenomena of the attack are thus described by Huguenin : ^ " Se- 
vere headache, just before the attack; after loss of consciousness has oc- 
curred, contracted pupils, not reacting ; in a few cases, paralysis of the 
facial nerve, on the side opposite to that of the hsematoma; sometimes 
hemiplegia. These latter symptoms only occur in one-sided hemorrhages. 
A marked change in the color of the face is another of the symptoms re- 
ported. At the commencement of the attack, which is usually sudden, 
the face becomes flushed ; the pulse is full and rapid, but soon grows small 

1 Ziemssen, Cyclopedia of the Pract. of Med., translation, vol. xii., p. 409. 



CHRONIC PACHYMENINGITIS WITH HEMATOMA. 45 

and irregular, aDd pallor succeeds the flushing. In some cases the pulse 
is slow ; in others there is an increase in rapidity, continuing up to the 
time of death. Contractures of the extremities, and slight transitory 
twitchings, were present in a few cases." 

Instead of hemiplegia there may be one-sided convulsions, but these 
depend very much on the degree of pressure exerted upon the cortex- 
cerebri. The condition, strange to say, is sometimes arrested after an 
indefinite period, and there is a return to the normal state, but traumatic 
hsematoma is usually fatal. 

Schuhberg^ assents to the view held by Herschl, Virchow, and Cru- 
veilhier, that hsematoma is always the result of fibrinous inflammation, 
and believes that the prognosis is grave. In this paper he considers the 
duration of a fatal case to be about one month. 

Causes. — Hsematoma is a disease of adult life, and twenty-two per 
cent, of the cases collected by Huguenin were between the seventieth and 
eightieth years, and Durand-Fardel found that 77.4 per cent, of all 
cases were men, and 22.6 per cent, were women. As causes may be men- 
tioned various cachectic and other diseases, among them Bright's disease, 
scurvy, syphilis, typhus fever, rheumatism, smallpox and scarlatina, al- 
coholism and sunstroke, or any condition which is conducive to continued 
hypersemia of the dura mater. 

Morbid Anatomy and Pathology. — The process involved in the 
production of hsematoma is an exceedingly complicated one, consisting in 
the production of new vessels and new layers -offibrine due to the extrava- 
sation of blood. The first layer of this new tissue-formation takes place 
in contact with the arachnoid, and ultimately others form and become 
organized. The formation of the blood-cyst is due to the rupture of one 
of the new vessels, and the extravasation becomes surrounded by a layer 
of tissue which may be so firm as to preserve the cyst contents unchanged. 
This is particularly the case in the smaller cysts. The skull is sometimes 
found to be thin as seen by Hyrtl,^ but this is not common, and some 
writers, among them Textor^ and Rokitansky,^ consider that the reverse 
is to be seen in a greater number of cases. I may briefly enumerate the 
post-mortem appearances as follows : Beneath the dura mater may be found 
a layer of coagulum W'hich contains fibrinous shreds binding it to the 
membrane itself. If the case be of long duration several layers of false 
membrane containing bloodvessels are to be found attached to the dura, 
and the late formations may be distinguished from those of early origin. 
Between these layers it is not unusual to find the results of interstitial 
hemorrhages which exist as blood-clots in different styles of organization. 
The thickening of the dura mater is thus described by Fox : " In the 
non-purulent form of the new formation, the result of inflammation be- 



^ Schmidt's Jahresbericht, vol. 104, pp. 164, 165. 

2 Ziemssen's Encycl., vol. xii. Am. Tran., Art. " Meningitis.' 

^ Wiirzburg Verhandlung, vii. 1857. 

* Eokitansky, quoted by Hnguenin. 



46 DISEASES OF THE CEREBRAL MENINGES. 

comes very quickly the seat of vessels and is composed of several layers ; 
those nearest the dura mater being composed of compact lustrous connec 
tive tissue fibres almost as dense as the dura mater itself, whilst the layer 
further removed from the dura mater is rich in cells with small narrow 
vessels, and the layer nearest the arachnoid, often firmly uniting 
the arachnoid to the dura mater, is remarkable for very large capilla- 
ries." 

The size of the hsematoma may vary from that of a small bean to that 
of an orange, and in one case, the autopsy of which was made by Dr. 
Huber of the Colored Home, the blood-cyst covered one entire side of 
the brain, and was fully an inch in depth. The patient was under the 
care of Dr. Whitall, who kindly contributes the following notes : — 

P. B., 60, widower, N. Y. ; mulatto ; father, mother, and one brother 
died of phthisis. The patient has been intemperate, but now drinks only 
in moderation. He denies venereal disease ; twenty-five years ago he had 
smallpox, and has since had intermittent fever and cholera. His trouble 
dated from an injury seven years ago. He was thrown from a hay-truck 
to the ground, falling upon his head, and causing blood to flow from his 
left ear ; but he was able to walk to his home, one mile distant. He 
seems to have received no very serious injury, if we may judge from the 
immediate symptoms. Since the fall he has been troubled with headache 
ofi" and on, increased by approaching a fire. He cannot appreciate the 
ticking of a watch pressed to his left ear. About a fortnight ago he had 
a chill, fever, and cough, some pain in back, with soreness around the 
whole gluteal region. Urination was slow, disturbed, and at one time he 
was unable to pass water ; at another it would be too free ; has been 
growing weaker since. 

Jans 15, 1874. On admission patient was confined to bed ; owing to 
apparent weakness in lumbar region he was unable to stand. In a few 
days he began to improve under the administration of iodide of potash. 
Walks with a staggering gait, and cannot follow a straight line. On 
closure of eyes does not have a tendency to fall. Heavy expression of 
countenance. No diminution in acuteness of sensibility can be discov- 
ered over any portion of the body. Had incontinence of urine on ad- 
mission ; is not so troubled at present time. Can walk about the ward ; 
at times can dress without assistance. To-day complains of frontal head- 
ache ; sleeps very soundly, with stertorous breathing. Appetite good ; 
bowels constipated. 

24^/i. Staggering gait, and inability to walk in a straight line, still 
present. If he closes his eyes while standing, there is a tendency (which 
by an efibrt he can overcome) to fall backward. Complains of pain on 
right side of head and face ; sleeps most of the day in a chair ; at night 
snores loudly. Bowels constipated. Nocturnal incontinence of urine 
exists. 

Feh. 6, 1875. To-day, while patient was sitting in a chair, he had a 
convulsion, and then became comatose. Urine albuminous. Ordered ol. 
tiglii TT]^ iv, after the action of which he appeared much better. 

Ibth. Very little change in patient's general condition since above note. 
Is still apathetic, and complains of pain in the head, on right side espe- 
cially. There is still right facial paralysis, with somewhat diminished 
sensibility in this region. The tongue deviates, if any, to the right. Pu- 



CHRONIC PACHYMENINGITIS WITH HiEMATOMA. 47 

pils normal in size and reaction. No notable change in hearing. No 
loss of motion, though the right arm and leg are weaker than the left. 
The lower limbs (left more i^eadily than right) can be drawn upwards, 
and extended with little trouble. He is unable to walk or stand without 
being supported, as the right leg gives away ; complains of a considerable 
pain in the upper portion of the limb. Has occasional involuntary pas- 
sages of urine and feces ; as a general thing, however, the bowels are con- 
fined ; urine evacuated wdth considerable force. 

March 19. Appears to be losing strength very rapidly. Will not an- 
swer when spokeu to. Temp. 99t°. • 

21st. Died about 9 P. M comatose. 

Autopsy 36 hour8 post-mortem — Eigor mortis marked. Body slightly 
emaciated. 

The dura mater was found very firmly adherent to the calvarium to 
the right of the longitudinal sinus, and over a considerable portion of the 
convexity. After removing the dura mater, the pia mater on the left 
side was discovered to be unusually dry and congested, with here and 
there slight patches of lymph. The convolutions throughout this hemi- 
sphere were greatly flattened, and the sulci nearly obliterated. In the 
right cranial cavity a large hiematoma existed. The tumor pear-shaped, , 
with a larger extremity anteriorly, extended from the anterior portion of 
the second frontal convolution to the posterior portion of the second tem- 
poral, and from within an inch of longitudinal fissure to junction of 
lateral portion with base of skull. 

The right hemisphere was correspondingly compressed downwards, 
backwards, and to the left. The depression corresponded to the shape of 
the tumor and w^as so situated that the greatest amount of pressure came 
upon the left lateral ventricle. The dimensions of this grow^th were as 
follows: 6 J inches antero-posteriorly ; 4 inches vertically in greatest 
diameter ; and about two inches in thickness. 

In addition to the h^ematom^, a serous cyst (about the size of a hickory- 
nut), evidently originating from an old hemorrhage in the subjacent 
brain structure, the cicatrice of which still remains, was seen beneath the 
anterior lobe. Back of this another cyst, the walls of which were chiefly 
composed of softened brain tissue, was discovered, which, upon closer 
investigation, was ascertained to be continuous with the right lateral ven- 
tricle through the middle cornua. The right ventricle was greatly dis- 
tended by serum, while coniparativelv little could be detected in the 
left. • " 

In the left ophthalmic artery a long, slender clot, partly dark and 
partly translucent and yellowish, existed. No thrombi were noticed in 
the slight atheromatous arteries at the base of the brain. 

No connection existed between the pia mater and the hematoma; 
the relations between it and the dura mater were so intimate as to require 
dissection before a separation was possible. 

The petrous portion of the right temporal bone was considerably larger 
than the left, and, upon section, proved to be much more porous. No 
other abnormalities were present ; no evidence of fracture at the base. 

The way in which the tumor, though situated on the right side of the 
brain, pressed upon the left ventricle, explained the symptoms which, 
during life pointed to an involvement of the left side ; and aiso oflfered an 
explanation as to the manner in which the fluid was forced through the 
middle cornua of the right ventricle. 



48 DISEASES OF THE CEEEBRAL MENINGES. 

Heart. — Yery flabby ; cavities dilated, and filled witb dark coagula. 
Aortic valves were slightly thickened, and the artery was atheromatous. 
Mitral valves thickened. 

Lungs. — The right was firn^ily bound to chest; very soft and congested. 
The surface was studded with pigment. 

The left had also become adherent to parietes, and, at the apex, a few 
softened, cheesy points were discovered. 

Spleen. — Enlarged and congested. 

Jv?'yer.~Normal. 

Kidney. — Cortex somewhat thicker than usual ; both organs were 
waxy. 

Weight of the organs. — Heart, 10 oz. ; spleen, 7 oz. ; liver, 55 oz, ; right 
lung, 29 oz. ; left lung, 18 oz. ; right kidney, 6 oz. ; left kidney, 5 oz. 

Prognosis. — The existence of a blood tumor of this kind is not al- 
ways a serious matter. Even after two or three extravasations have oc- 
curred, a retrogressive course takes place ; but this is rare. Griesinger ^ 
reports a case in which partial recovery has taken place ; and in 1876 the 
patient was still alive, and presented slight evidences of his former serious 
.trouble. This termination of the disease is exceptional, however. 

Treatment. — What has been said in regard to the management of 
uncomplicated pachymeningitis is applicable in this disease ; and, in addi- 
tion, venesection has been advocated by more than one authority. It 
should be employed during the comatose stage which marks the occur- 
rence of an effusion, and at the same time a drastic cathartic, will be 
found to be of excellent service. High living and excessive use of to- 
bacco and alcohol are to be interdicted, and iodide of potassium may 
be given with the idea of producing absorption of the new growth. 

ACUTE CEREBRAL MENINGITIS. 

The term meningitis has been applied, clinically speaking, to that form 
of inflammation w^hich involves chiefly the arachnoid and pia mater, and 
in its acute form may be expressed by the following grave and alarming 
symptoms : — 

Symptoms. — These may be divided in regard to. their appearance 
into three stages : 1st. The stage of excitement or irritation; 2d. The 
stage of delirium ; 3d. The stage of stupor. 

An hypothetical case may be presented. The patient complains of a 
slight headache, which increases toward the end of the first twenty-four 
hours. It may not be attended by much annoyance, and he is usually 
able to attend to his daily duties, but during the succeeding six or eight 
hours it may become greatly aggravated, and is attended by reytlessnes^s, 
flushing of the cheeks, throbbing of the temporal vessels, and general dis- 
comfort. After a few hours there may be slight rigors or a severe chill, 
which is often mistaken for ague ; and the rapid elevation of temperature, 

^ Archiv. der Heiikunde, 1862. 



ACUTE CEREBRAL MENINGITIS. 49 

and hard, bounding pulse may strengthen the suspicion. The headache 
continues, and is still not confined to any particular locality, but is so in- 
tense that the patient seeks his bed, where he may lie, moaning, sighing, 
or tossing restlessly to and fro. The muscles of the legs may twitch, and 
the least noise, such as the creaking of a door, invariably irritates and 
startles the invalid ; bright lights distress him, and he closes his eyes in- 
stinctively. He keeps his hands over his ears so that he may not hear 
noises in the room, or firmly presses his aching temples. There may be 
vomiting which is not dependent upon the condition of the stomach, is not 
attended by retching, and occurs whether the stomach be empty or fall. 
If the patient be a child, there are generally convulsions of a very violent 
character. These constitute the first stage. 

Active delirium usually appears during the first two days, and continues 
through the greater part of the second stage. The patient screams in an 
agonizing manner, and alarms those who may be with him, adding greatly 
to the distressing character of his sufierings. The delirium now begins to 
subside, or may be supplanted by coma. The temperature becomes lower, 
and the pulse loses much of its force and rapidity. The head is hot, and 
the respiration becomes irregular and sighing. The bowels, which were 
constipated in the first stage, still continue so, and the tongue is coated 
with a dirty-white fur. There may be convulsions at this time, which 
RamskilP says may precipitately throw the patient into the third stage, 
which is one of collapse. This stage may resemble that of advanced ty- 
phoid. Sordes on the teeth, pinched features,,dark circles about the eyes, 
fluttering pulse, great prostration, with loss of muscular power, dilated 
pupils, stertorous breathing, and the unconscious passage of feces and 
urine, are all forerunners of death. Should the force of the inflammation 
be exerted at the base, the symptoms are much more violent, and paraly- 
ses of cranial nerves are not uncommon. 

Causes. — In considering the predisposing causes of acute meningitis 
it will be well to inquire what are the influences of sex and age. The re- 
ports of the New York Board of Health show that during the years 1867, 
1868, 1870, 1871, 1872, and 1873 there were 4321 deaths from meningitis 
in the city of New York, 2506 of whom were males, and 1815 females ; 
8434 were children under 5 years; of these 1873 Avere males, and 1561 
females. It will therefore be seen that males are more often affected than 
the other sex, and that the large proportion of cases occur among chil- 
dren. 

Rilliet and Barthez take an opposite view of the matter, and consider 
the disease to exist more frequently after the fifth year. My own experi- 
ence and the Health Board's statistics lead me to think that after this 
period of early life, the adult cases are comprised in the interval between 
the twentieth and fiftieth years, and I am unable to find the records of 
many cases after the sixtieth year, and am therefore disposed to believe 
that the disease is rare after that time. Various predisposing causes give 

^ Article in Reynolds' System of Medicine, p. 369, vol. ii. 



50 DISEASES OF THE CEREBRAL MENINGES. 

rise to the affectioD, and none, I think, plays a more important part in 
the production of the adult variety than continued dram-drinking; and 
hard work in warm places. Over-use of the mental powers, and various 
disorders, such as syphilis and gout, are favorable to its development. 

Croupous pneumonia, acute rheumatism, diphtheria, extension of dis- 
ease from the tympanic cavity, blows upon the head, and sudden changes 
of temperature of any kind, are the direct causes of acute meningitis. In 
one of my cases the disease was the result of a sea-bath. The patient, 
after bathing, sat for some time with uncovered head upon the beach ex- 
posed to the heat of a noonday sun. Haeddeus^ reports a case of this dis- 
ease which resulted from typhoid fever. 

Diagnosis. — Acute cerebral meningitis may be mistaken or con- 
founded with cerebritis, typhoid fever, or delirium tremens. The deli- 
rium, headache, and disorders of motility are much less marked in 
cerebritis than in acute meningitis, and it must be remembered that the 
pulse in the latter disease is much more rapid and full, and the tempera- 
ture much higher. 

Typhoid fever is symptomatized by elevation of evening temperature, 
diarrhoea, abdominal tenderness and tympanites, muttering delirium, and 
the presence of petechise. Delirium tremens may be occasionally con- 
founded with the disease under discussion, but it must be remembered 
that the history of alcoholism — peculiar delusions and alcoholic delirium, 
the absence of headachy and the condition of the skin, are all evidences of 
delirium tremens, which are not to be mistaken. 

Pathology and Morbid Anatomy. — When the pia mater and 
arachnoid become the seat of inflammation, we may roughly group the 
lesions and consequent symptoms into two classes, one indicative of basal 
trouble and the other of vertical. In the former, cranial nerve-trunks 
will be injured or diseased ; while in the latter, the investing membranes 
of the cerebrum will be the seat of morbid action, and the functions of the 
cortex must be consequently destroyed, so that the symptoms will be more 
of a psychical character than when the base is involved. 

The recent investigations and contributed cases of Landouzy,'^ of which 
104 are presented by this author, demonstrate the connection between cer- 
tain symptoms and lesions of the description to be hereafter mentioned, 
involving those portions of the cortex containing the centres of Hitzig' 
and Fritsch. These prove very clearly that violence of the inflammatory 
process in certain places may be attended by certain paralyses or contrac- 
tions of limbs which are innervated from these centres. A case which 
recently came under my observation is one of this kind, and possesses 
great pathological interest. 

E. B., aged thirty-six, born in Ireland, by occupation a blacksmith, is 
a stout, well-made man of nervous temperament, and up to the commence- 

1 Berliner Klin. Woch. 1869, p. 564. 

'^ Contribution £L I'^tude des Convulsions et Paralyses liees aux Meningo-encephalitis 
fronto-pari^tales. Paris, 1876. 

' Reichert and Du Bois Eejraond's Archives, 1870, Heft 3. 



ACUTE CEREBRAL MENINGITIS. 61 

ment of his present trouble had enjoyed uninterrupted good health. He 
has not had syphilis, and his habits have been good. His mother and 
father are dead, the former having died of old age and the latter of phthi- 
sis. There is no family history of insanity, epilepsy, paralysis, nor of any 
organic nervous trouble whatever. Ten years ago, while working upon a 
fire-escape, he fell to the ground, two stories below, striking upon his head 
and shoulder. He was taken up unconscious, and remained so for four- 
teen hours. The only injuries he received were two severe scalp-wounds, 
one of which, from its slowness in healing, must have been attended by 
some bone injury, for he was unable to resume work until three months 
later. He says that purulent accumulations took place, and that " the 
doctor lanced them." Two cicatrices are now visible, one of which is 
about an inch and a half long, and is situated on the left side of the head 
and covers a depression about three-quarters of an inch in diameter and 
one-quarter of an inch in depth, the centre of which is about one and one- 
half inches below the median line, five inches above the left ear, and four 
and three-quarters inches above the centre of the left supra-orbital arch. 
This is the only depression visible, and the injury on the right side was 
apparently very superficial. 

He gives no history of serious head symptoms, and when he resumed 
work was in good condition, there being no paralysis. About three months 
later he noticed a tremulousness of the fingers of the right hand and 
afterwards of the arm of the same side. There was no pain nor loss of 
power, but simply a marked tremor whenever he attempted to do any- 
thing. This difiiculty increased to such an extent that he was obliged to 
resign his position as first-class workman, and become a helper, using his 
other arm to work the bellows. About six months after this the tremor 
affected the right leg, and he was obliged to leave his work. 

Present Condition — The patient does not complain of head symptoms, 
except a slight hypersesthesia of the right side of the face, of short dura- 
tion. Vision normal ; fundus of either eye presents no abnormal appear- 
ances ; pupils respond well to light, and are of equal size. Hearing 
unaffected. No tremor of face or tongue, speech unembarrassed, mem- 
ory good, and no intellectual trouble whatever. He has never had head- 
ache. 

Upper Extremities. — Left side unaffected. The right hand and arm 
are perfectly quiet during inaction, but when the most simple voluntary 
act is attempted they become agitated by a fine rhythmical tremor, which 
becomes more marked as the accomplishment of the act requires greater 
nicety of coordination. When he is asked to carry a glass of water to his 
mouth, he spasmodically grasps the vessel and carries it upward, the elbow 
being raised, the tremor meanwhile increasing until the mouth is reached, 
when the movements become so violent that he is unable to place the rim 
of the glass between his lips. Certain motions are almost entirely unat- 
tended by tremor. He can extend the arm and hand, or can hold them 
rigidly upright, and is able to pronate the hand, but movements of flexion 
are attended by increased violence of the tremor. Tactile sensation ia 



52 DISEASES OF THE CEREBRAL MENINGES. 

somewhat impaired, but susceptibility to painful impressions is not dimin- 
ished. There is absolutely no loss of muscular power, no atrophy of the 
hand or arm, the thenar eminences being covered by firm cushions, and 
the interosseous spaces being well filled. 

Lotver Extremities. — The left leg, like the arm, is in no way aflTected. 
The right leg, however, is agitated by muscular tremor when he attempts 
to use it, or approximates it with its fellow, as in standing erect. There is 
no loss of muscular power, but some anaesthesia, the patient being unable 
at any place to distinguish two points of the sesthesiometer, unless they are 
separated at least eight centimetres. 

When he stands with his eyes closed he is " groggy," but does not fall. 
He can stand upon the right foot alone, but not upon the left. When he 
walks, the right heel is brought down first, so that the heel of the shoe is 
much worn. He has some plantar formication and coldness of the foot. 
He has suffered from pains of a pseudo-neuralgic nature in the right 
shoulder and right thigh, which were centrifugal, as well as some pains 
which darted from the heel up the inner side of the leg. The pains in the 
upper extremity are not so frequent as they were a year ago. There has 
been no history of body-constricting band, pain in the back, or vesi- 
cal trouble of any description, but for the past five years he has been 
constipated and obliged to take purgatives. There are no contractions 
whatever. 

The peculiarities of this case seem to be the unilateral tretnor (not 
disorderly movements) excited by voluntary exertion, its predominance 
in flexion, while certain movements of extension are almost unattended 
by any embarrassment, the absence of muscular weakness, contractions, 
or atrophy, and the evident dependence of the trouble upon a localized 
cerebral injury of the opposite side, which probably resulted from the 
fall. 

I am unable to arrive at any conclusion which would lead me to consi- 
der the symptoms due to cerebro-spinal sclerosis, or one-sided posterior 
spinal sclerosis, if the latter anomalous condition could exist. The utter 
absence of loss of power and permanent contraction of the affected limbs, 
and the non-extension of the affection to those of the other side of the 
body within ten years, are sufficient to invalidate such a diagnosis. 

The non-occurrence of convulsions and other symptoms of cerebral 
tumor renders this as a cause of the tremor quite improbable. 

Of course the assumption that this patient's symptoms are due to some 
irritative meningeal or cortical lesion must be based upon purely theoreti- 
cal grounds, but the features of the case convince me that such a [condi- 
tion of affairs is by no means improbable. If we refer to the charts of 
Hitzig and Ferrier, we shall find that they have located a cortical region 
which is " situated on the ascending frontal, just behind the upper end of 
the posterior extremity of the middle frontal convolution," which " is the 
centre for the movements of the hand and forearm in which the biceps 
is particularly engaged, namely, supination of the hand and flexion of the 



ACUTE CEREBRAL MENINGITIS. 53 

forearm."^ Again, if we consult the admirable article of Turner,^ we 
shall find very useful hints which will enable us to lay out the exterior of 
the cranium into regions corresponding with the convolutions beneath. 
One of these areas, which has been called the upper antero-parietal space, 
includes the ascending parietal and ascending frontal convolutions, and 
an injury at the point I have located in describing this case would be 
just over the centre, which, when experimentally irritated, produces 
movements of flexion and supination. 

It is quite reasonable to suppose that this irritation occurring with voli- 
tional movements is due to a natural increase in the blood pressure during 
mental activity, a consequent increase in cerebral volume, and a resulting 
meningeal contact with the depressed portion of bone, which probably 
does not impinge upon the cranial contents at ordinary times. 

Dr. James B. Ayer ^ reports an extremely interesting case of cerebral 
syphilis, the prominent feature of which was the presence of hallucina- 
tions of hearing, the lesion being syphilitic meningitis, evinced by great 
pain confined to the back part of the head, and psychical symptoms of 
interest, such as sluggishness of intellect, unreasonable dislikes, and insane 
hallucinations of hearing. The autopsy revealed a significant condition 
of affairs, namely, a patch of induration of certain occipital convolutions 
which bears out the statement of Ferrier that auditory disturbance ordi- 
narily follows lesion of this part of the brain. 

" Both tables of the skull were somewhat .thicker than usual, at the 
expense of the diploe. The calvarium was heavy and dense ; in other 
respects normal. The dura mater was ordinarily transparent. A recent 
coagulum was found in the longitudinal sinus. There was nothing special 
in the pia, except that a patch, the size of a half dollar, over the upper 
occipital convolutions of the right side was adherent to the brain. 

" The middle cerebral artery of. the right side contained a small spot 
of chronic endarteritis, which had diminished the calibre of the vessel 
about one quarter. There was a similar patch. in the basilar artery, of 
somewhat larger size. The intima ran smoothly over these projections. 
On section they were found to consist of a yellowish-white, opaque tissue, 
and presented a marked contrast to the surrounding healthy tissue. The 
convolutions were somewhat flattened ; the ventricles contained a trifle 
more fluid than normal, 

" IS ear the longitudinal fissure, in the upper part of the right occipital 
region, between two occipital convolutions, there was an indurated portion 
of brain corresponding to the patch of meningeal inflammation. The 
gray matter was found atrophied to one half its normal thickness. The 
neuroglia in the white substance beneath was increased, and the white 
substance exhibited a grayish tint, but nothing else abnormal." 

^ Functions of the Brain, page 307. 

2 Journal of Anatomy and Physiology, vols, xiii., xiv., November, 1873, May, 
1874 
' Boston Med. and Surg. Journal, Sept. 19, 1878, page 363. 



54 DISEASES OF THE CEREBRAL MENINGES. 

In the majority of cases the inflammation begins at the base and extends 
upwards. The temporal lobe may often be its starting-point, while in 
other varieties the meninges covering the cerebellum may alone be in- 
volved. The appearance of the cranial contents cannot be mistaken, the 
membranes are red, hypersemic and attached to each other, and the arach- 
noid cavity contains a considerable quantity of serum. The fluid in the 
ventricles is increased and may contain pus, and the choroid plexuses 
are found to be turgescent and enlarged. It may be stated upon the au- 
thority of Huguenin^ that in some cases the ventricular fluid is 
purulent on one side, while it may be simply serous on the other. In 
aggravated cases the quantity of pus may be considerable, and if the 
meningitis be of the basilar form the pia mater of the base will exhibit ex- 
tensive purulent infiltration. The ependyma of the ventricles may be 
thickened granular, and contains yellowish deposits. In cases due to 
traumatism, or extension of other diseases, there may be found evidences of 
caries or fracture. The cortex in nearly every case of meningitis of the 
convexity is found to have undergone decided softening, and when the 
meninges are removed, some of the superficial brain-substance is carried 
with them. Microscopic examination will reveal cortical changes of more 
or less recent date. The vessel coats are shrunken or hard, and areas of 
sclerosis, or on the other hand breaking down, are to be recognized. 

Prognosis. — We should always hesitate in expressing our opinion as 
to the course of the disease, although so few cases get well that it is almost 
safe to say that our patient cannot recover. The prognosis of syphilitic 
meningitis is by no means hopeless. There may be a gradual return to 
health characterized by occasional exacerbations of pain, mental listless- 
ness, etc. If the patient improves after the first week, we may consider 
the prognosis much more hopeful, but there are often deceitful lulls 
which may mislead the medical attendant. ^ Dr. S. G. Webber reports 
a case in which there was a return of intelligence just before death, which, 
however, was temporary. If active treatment produces beneficial results, 
his chances are better, while any evidence of ocular trouble, and conse- 
quently basal involvement, lessens the patient's chances materially. 
Should the disease result from extension or inflammation of the temporal 
bone, the prognosis is also grave. Death may occur in four or five days, 
or even in a shorter time, but the duration of the disease may extend to 
the tenth day. 

Treatment. — Two indications are to be met promptly : one the ab- 
straction of blood ; the other, cold to the head. When the delirium is 
furious, temporal vessels swollen, and the pulse hard and bounding, ab- 
straction of blood from the arm is to be immediately resorted to. A sug- 
gestion made by Holland many years ago is one of value, notwithstand- 
ing the fact, that it has been almost forgotten and generally disregarded. I 
allude to the application of leeches to the hsemorrhoidal veins ; to use his 

1 Ziemssen's Encyclopaedia, vol. xii., translation. 
2Bost. Med. & Surg. Journal, Vol. ci., p. 361. 



RHEUMATIC MENINGITIS. 55 

words : " I know of no mode in which a given quantity of blood can be 
removed in equal effect in cases where it is required." ^ Cold to the 
scalp either by ice-bags, or by a bladder filled with pounded ice, or an 
arrangement of rubber tubes, should be employed, and will be found to 
very speedily relieve the pain. Accepting a hint from Dr. Chamberlain, 
of this city, I have had constructed, and have successfully used an apparatus 
such as I will describe. It consists of a long piece of rubber tubing 
wound upon itself and securely held in its spiral form by tape, forming a 
skull cap. The upper end is connected with an ice-cooler or a cold water 
tap, should there be one in the apartment ; and the other is fitted with a 
stopcock so that the discharge of water may be regulated. By this means 
the patient's head can be kept cool and his bed dry and comfortable, an 
impossible state of affairs where the douche is used. Iodide of potassium in 
large doses has been given with excellent effect, and its efficacy in this dis- 
ease has been praised by Fliat, Alonzo Clark, and others. Aconite, ergot, 
and the bromides are all efficient remedies in depressing the pulse and 
quelling the delirium ; and elaterium, saline cathartics, or the old com- 
bination of salts and senna may be of service. Blisters applied behind 
the ears and to the neck are excellent adjuvants. Should the patient's 
strength be reduced, as is the case in the later stages, the free use of 
stimulants, nourishing food, such as milk, egg-nog, beef-broths, and nu- 
tritious but digestible food, are of great importance. In the other forms 
presently to be alluded to, we should be governed by the existence of 
rheumatism, or the advanced age of the patient, and for the former pre- 
scribe alkalies, colchicum, and other remedies of the same nature, and for 
the latter a generous diet and a liberal use of stimulants. 

KHEUMATIC MENINGITIS. 

A form of inflammation of the meninges may be connected with, or 
occur during the course of acute articular rheumatism, or again it may 
be found without any coexisting joint trouble. 

Trousseau^ has described three forms of cerebral rheumatism. One of 
these he calls apoplectic, and it is symptomatized by coma without paraly- 
sis ; a second form, first described by Gosset, is that in which delirium 
is followed by coma ; and there is a third in which delirium makes 
its appearance in the course of inflammatory rheumatism. Its co-exist- 
ence with joint-trouble is by no means the rule, though the majority 
of cases reported have been of this character. Posner ^ reports a case in 
which the inflammation left the joints and attacked the meninges. Pain 
in the head, delirium, and slow pulse were the prominent features of the 
patient's illness, and recovery took place in about two weeks. The symp- 
toms of an ordinary attack of metastatic rheumatic meningitis are these : 

^ Quoted by Sollv. The Human Brain, etc., page 353. 

2 Schmidt's Jahresbericht, vol. 113, p. 25. 

^ Encephalopathia Eheumatica, Ibid., vol. 104, p. 167. 



56 DISEASES OF THE CEREBRAL MENINGES. 

Either during an attack of acute rheumatism, or afterwards, the patient 
may become dull and stupid, and delirium makes its appearance. This 
delirium is of a violent character, and during its existence the patient 
may have delusions and hallucinations of sight and hearing. In a case 
reported by Mesnet^ the delusions of persecution were a prominent fea- 
ture, but there is no regularity in this mode of expression. There is 
usually but a slight rise of temperature, though it may sometimes attain 
an elevation of 106°, or thereabouts, and the pulse at the same time be- 
comes very rapid and full. Headache of a very severe variety, such as I 
have described when speaking of the other forms of acute meningitis, may 
be present throughout the illness, and, after several days, choreiform 
movements may occur, and with their advent the delirium, which was 
before inconstant, but now becomes continuous. These choreiform move- 
ments are such as a nervous embarrassed person would make in health when 
suddenly disconcerted. There is an uneasy opening and closing of the fin- 
gers, and the arm is jerked backwards and forwards. The patient now 
finds considerable difficulty in swallowing, portions of food remaining in 
the mouth for some time. Great prostration and collapse may supervene, 
and he dies in a comatose state, or, on the other hand, there may be slow 
recovery, the mental symptoms being the last to subside. 

Vomiting and early headache, which are so characteristic of the other 
forms of meningitis, are absent. Recovery is rare, and of thirty-nine cases 
reported by Vigla,^ thirty terminated fatally. Should the patient sur- 
vive, he is very apt to become insane, the varjety of such mental trouble 
being chronic mania. Huguenin^ considers that the connection of 
meningitis with rheumatism is threefold with respect to pathological 
changes : — 

" a. Endocarditis is the connecting link, so that the combination is 
rheumatism, ulcerative endocarditis, meningitis. 

" h. Purulent inflammations of the serous membranes form the con- 
necting link, endocarditis being present or not, as may be. In this case, 
purulent meningitis is secondary to purulent inflammation of the serous 
membranes ; this is very rare, and the exact connection is unknown. 

" c. Meningitis complicates rheumatism without there being any puru- 
lent deposits in the body, or any aflection of heart ; the connection here 
is also obscure." 

Da Costa* is inclined to refer the brain symptoms in cerebral rheuma- 
tism to two agencies, the first of which is circulation of vitiated blood, 
and the second is the disturbance of cerebral circulation dependent upon 
the plugging of small arteries by fine embola, and he consequently considers 
cerebral rheumatism to be a disease which is not essentially an inflamma- 
tion of the cerebral meninges. 

^ Archives Generales, June, 1856. 

^ Actes de la Soc. Med. des Hopitaux de Paris, 1865, 3me fas. 

»0p. cit. p. 624. 

* American Journal Med. Sciences, Jan. 1875. 



MENINGITIS OF THE AGED. 57 

A case of rheumatic meningitis which recovered under the use of cold 
baths — and was treated by M. Fereol/ of Paris — is the following : 

The patient was thirty-four years old, of quiet and temperate habits, 
who was suffering from acute articular rheumatism. He was treated at 
first with emetics, sulphate of quinine, and colchicum, but in five days he 
was seized with delirium, and dyspnoea, and at the same time the 
pains in the joints disappeared. The temperature of the body rose to 
forty degrees (Centigrade), and leeches, calomel, and bromide of potas- 
sium were given without success. The temperature rose further to forty- 
one degrees, and blisters were placed on the scalp, and digitalis was 
given. There was then a little more rest, but the aspect was typhous, 
with stupor and continuous sub-delirium ; sleeplessness, agitation of the 
muscles, subsultus tendinum, dry tongue, etc. After some consultation 
with other physicians, it was determined to try the effects of cold baths 
as the only remaining resource. This plan was pursued for a whole week, 
the patient remaining under close observation the whole of the time, and 
the thermometer being almost fixed under the axilla. As soon as the 
temperature rose to 39.5° the patient was plunged into a cold bath. 
From the 25th of February to the 3d of March sixteen baths were ad- 
ministered at a temperature varying from twenty-one to twenty-five de- 
grees (Centigrade), and the duration of each bath was twenty minutes on 
the average. The patient always raised the temperature of the water 
from one to two degrees, and, on leaving the bath, his own temperature 
fell to thirty-six degrees. After several fluctuations and much anxiety 
on the part of the medical attendants, the patient eventually recovered 
completely. 

MENINGITIS OF THE AGED. 

According to Prus,^ meningitis of very old persons rarely presents the 
same symptoms as do the forms of early or middle life. In the morning the 
old man or woman is stupid, but conscious ; speech is thick, and there is 
general headache and moderate fever. The warmth of the body is nearly 
normal, except at the head, where it is markedly increased. In the even- 
ing it is elevated. 

The eyes are injected, and there is low delirium. Incoherence and 
restlessness, during the night, and an uneasiness which is expressed by 
walking about the house and going from one bed to the other, are mani- 
festations which are characteristic.^ If the disease is to end fatally, the 
patient becomes comatose, and dies within a week, or twenty days at the 
longest, from the commencement of the disease. These patients very 



^BulL Gen. de Therap., Mar. 30, 1875. Med. News, 1875. 

2 Quoted by Grisolle, vol. i. p. 430. 

' Eamskill speaks of the eccentric behavior of these patients, who may use the spit- 
toon instead of the chamber pot, or commit other violations of decency. In one case 
■which came to my knowledge, the patient urinated against the bed-post, and went 
about the house with his trowsers always unbuttoned. 



58 DISEASES OF THE CEREBRAL MENINGES. 

often suffer for some time before the actual attack, when there may be 
partial paralysis, slight wandering of the mind, and insomnia. The 
general indications for treatment of the other forms are applicable in 
these cases. 

The mental disturbances are those of senile dementia, and are distinctly 
asthenic. The old man is querulous and irritable. He delights to talk 
of his early life, but cannot tell you what has occurred within a few 
hours. If the condition be profound, he will sit quietly by himself, groan- 
ing and complaining. He goes frequently to stool, or, more commonly, 
unconsciously passes his feces and urine. 



ACUTE GRANULAR (TUBERCULAR) MENINGITIS. 

Dr. Robert Whytt^ was the first to describe this disease, and so satis- 
factorily did he do so, that even after a hundred years there is very little 
to add to his accurate description. We shall have to study the disease as 
occurring in two different ways. It may be primary, and have a doubtful 
tubercular character, or may occur in connection with some thoracic or 
abdominal disease, and like the other forms of meningitis, may be confined 
to the base or convexity. 

Symptoms. — Though many of the symptoms are the same, there are 
a few points of difierence, which are the following : — 



Predominant Indicative Symptoms. 

BASAL. VERTICAL. 

Vomiting, constipation, infrequent or Convulsions with intervala occupied 
irregular pulse, unequal pupils, stra- by tremor, twitching of limbs and mus- 
bismus. cles of the face, turning of thumbs in on 

palms, clenching of fists, frequent pulse. 

When the base is involved, the symptoms may be grouped in three 
stages, which run their course in from four to twenty-four days. The 
child may be puny and delicate. He may lose flesh and complain of 
headache. His skin may be white and waxy, and there may be a ten- 
dency to flushed cheeks, loss of appetite, and capriciousness about food, 
and at night he does not sleep soundly, but starts and cries out. I have 
known children to seek the companionship of some other member of the 
family, fearing to be left alone. The child may moan in its sleep, grind- 
ing his teeth and lying with eyes widely opened. During the day he is 
disinclined to play, and seeks some quiet place in which to fall asleep or 
remain by himself Study is irksome, and so are all other forms of men- 
tal application. Irritable or languid, he attracts the attention of the 



1 Works of Dr. Whytt, Edinburgh, 1768. 



ACUTE GRANULAR MENINGITIS. 59 

mother by his behavior, which is so markedly changed. During this 
period I have found that headaches and crying-spells are not uncommon 
precursors of the actual acute disease, which may begin after two or three 
months. 

Marshall Hall/ in his description of the hydrocephaloid diseases, al- 
ludes to the importance of vomiting as an early symptom. " The most 
frequent and formidable in appearance . . . . is vomiting. Never, 
never allow vomiting in an infant to pass without paying the utmost at- 
tention, and making the strictest inquiry in reference to the functions of 
the brain." Vomiting is generally the first and most important symptom, 
and convulsions are next in importance, but these two may be associated 
or appear alone. Vomiting may be frequent, and is nearly always ac- 
companied by an aggravation of the symptoms of the premonitory stage. 
Headache and increased temperature are present, and are very decided 
evidences of the gradual development of the trouble. When we arrive at 
this stage, which lasts two or three days, we may expect the appearance 
of the following symptoms : A marked rise of temperature, say from 101° 
to 105° F., with greatly increased pulse. The bowels are still constipated, 
and there is but little appetite. The patient is delirious at night, and 
shrieks, cries, and tosses continually. At about the sixth or seventh day 
of the disease, there are various local troubles, such as unequally dilated 
pupils, slight strabismus, but no actual loss of consciousness as yet. There 
is a slight increase in the evening temperature, and the pulse is irregular 
and ranges from 110 to 120. The tenth day finds him much worse; his 
excited condition being supplanted by one of stupidity. He does not re- 
cognize those in the room, and is utterly indifierent to the kind attentions 
of his mother or nurse. When the finger is drawn across the skin it 
leaves a vivid red mark, which has been considered one of the strong 
pathognomonic signs. The pulse is greatly accelerated, and perhaps 
reaches 170, while the temperature may be found to be 104° or 105°. His 
condition during the tenth and eleventh days is very little changed, 
though the apathy is if anything exaggerated. The belly is retracted, 
and his facies is highly characteristic, the patient having a worn and 
pinched look. The skin is dark and congested, and his eyes may be fixed 
and immobile, and there may be either strabismus or a rolling upwards 
of both eyeballs, so that a large part of the sclerotic is exposed. Subsul- 
tus tendinum and "picking at the bedclothes," with involuntary passage 
of feces and urine, are grave forerunners of a fatal termination. The 
pupils are dilated, the pulse small, thready, and quick, and respiration is 
very slow. The temperature is still high, though the surface may be cold 
and clammy, and just before death the pulse quickens and becomes al- 
most imperceptible. Slight rigidity now becomes apparent, the patient 
cannot swallow, stertor follows, and then death. Marshall HalP tersely 

^ Lecture on the ISTervous System and its Diseases, L. and E. Pliiladelphia, 1836, 
p. 92. 

2 Op. cit., p. 93. 



60 



DISEASES OF THE CEREBRAL MENINGES. 



describes this last stage as follows : " The third stage is denoted by coma 
and its concomitant diminution of the sentient and voluntary system, 
and eventually of the powers of the excito-motory system. There are 

Illustrative Chart of Temperature. 
Pulse and Eespiration Variations in Acute Granular Meningitis. 



Days ot 
Disease. 


/ 


2 


3 


^ 


s 


[ — ' 
6 


7 


^' 


9 


JO 


/; 


/-2 


;^ 


/^ 


;x 


/6 


/7 


/^ 


<^ 

s 

X 

id 

» 

K 

i 

El 

K 
g 

O 

g 

s 


107° 


ME 


ME 


M E 


ME 


ME 


M E 


ME 


M E 


M E 


ME 


ME 


ME 


M E 


M E 


M E 


M E 


M E 


M^E 


106° 






































105° 

103° 
102° 
101°" 

Too°" 




































/ 




































/ 


















/\ 


/ 






/ 






/I 


— ^ 








/I 








/ 








1/ 


/ 


/ 


l/ 




^ 










/' 




/\ 


/ 


j 


\A 




r 


1/ 


1/ 


V 


V 












/ 


^ 


\A 


ij 


V 


V 




V 


















180° 


/ 




































/ 






































































u-m 


Tzo^ 






























/ 








160° 
























^ 


X- 


"■"" 










150 
140 
l30~ 






















/ 














- 






















/ 


































/ 


l' 
















120 
100 




















/ 






















/ 


\ 










.^ 


J 




















> 


/ 


\ 








f 


^ 




















90 

80 
^0~ 
"60~ 




/ 






V^ 


^ 




/ 






















/ 












^/ 
































































































50 

45 

~40" 














































































































35 

20~ 
15~ 
























































/ 


s 


.A 


r 




o"^ 


v 


.-- 


/^ 


^ 


V 


/^ 


A 


.<^ 




/^ 


^ 


A 


y 


>v 




/ 


*S^ 












V 




\ 




^' 




V 






















— 




_J 




^ 


— 




. 




















= 



A. Indicates sthenic character. 

B. Indicates irregularity. 

blindness, deafness, deep stupor, absence of voluntary motion. At first 
the eyelids are constantly half closed, but dill close completely on touch- 



ACUTE GRANULAR MEXIXGITIS. 61 

ing the eyelash. Afterwards this excito-motory phenomenon ceases. 
The respiration becomes irregular, alternately suspended and sighing, and 
at length stertorous. The sphincters lose their power, and the feces and 
urine are passed unconsciously." The appearance of the little patient 
just before death, is unmistakable. He lies with koit brow aad flushed 
face, one side of which is drawn, while the eyes are fixed and glassy, and 
utterly devoid of expression. 

The duration of the disease rarely exceeds twenty-four days. It will be 
well to dwell more fully on certain symptoms. Temperature. — There 
seems to be at first an elevation of temperature, which lasts through the 
first few days, say three or four, and after this time the temperature falls, 
until the sixteenth or eighteenth day, when it may either go much lower, 
or be again increased. The variations are between the normal standard 
98.2°, and 105°. It however rarely reaches this high point. The sur- 
face temperature of the body is much diminished during the latter stages, 
but the head is always hot. Pulse. — Infrequent and irregular pulse is 
characteristic of the earlier stages of this disease, and during the last days 
there is increased frequency and more evenness. During the first two 
weeks this infrequency is to be observed, but after this it may steadily 
increase ten, twenty, or thirty beats more each day until at last it cannot 
be counted. This rule is not without its exception, and I have found 
intervals when both temperature and pulse would fall to the normal stand- 
ard, and continue so for some days, and afterwards rise. The pulse is 
perhaps more rapid when the disease is being developed. I append a 
chart, which will enable the reader to see at a glance the condition of 
pulse, temperature, and respiration in a typical case. Various modifica- 
tions of the cutaneous circulation have been dwelt upon by Trousseau and 
various writers. There seems to be an extensive disturbance of the vaso- 
motor distribution of the skin, and when the surface is brushed or rubbed 
ever so lightly, or even when slight pressure has been made by the pillow, 
there will remain a bright red mark. This condition of the cutaneous cir- 
culation is not limited to the integument of the head, but may be present, 
especially towards the end of the disease, over the whole body. Trous- 
seau^ has called attention to the " tache-cerebrale," which is the name 
given to the appearance presented when the finger is passed over the sur- 
face, and a red line remains. 

This author found that when he made cross-markings upon the abdomen, 
in less, than half a minute the portion of skin which he had touched was 
sufi"used with a very bright red tint, which disappeared slowly, the lines 
made by the finger-nails remaining after the others had faded out. The 
regions where this redness is produced most easily are the anterior parts 
of the thighs, the abdomen and face. Respiration. — There are the usual 
fall and irregularity which accompany collapse of all kinds ; and sighing 
and diminished respiration are features of the later stages. Sensorial 
Disturbances. — Headache of a deep and throbbing character is very severe 

^ I ectures upon Clinical Medicine, Am. edition, vol. i. p. 877. 



62 DISEASES OF THE CEREBRAL MENINGES. 

and continuous, lasting until coma supervenes. Various indications of 
the patient's sufferings are conveyed by his behavior. He presses his 
thumbs against his temples, or locking his fingers on top of his head, 
holds his head in his hands, and gives vent to suppressed groans or 
shrieks, holding his breath sometimes as if fearing that the very effort of 
expiration might increase the pain. The cry of the patient is heart-rend- 
ing, but I am not disposed to agree with Trousseau that it has any decided 
periodicity, though there are intervals of silence. Hyperesthesia of 
the scalp, photophobia, and tenderness of the muscles at different parts 
of the body are usual accompaniments. Bertalot^ of Pfeddersheim, in 
an analysis of 24 cases, has found photophobia to be more commonly a 
symptom of the later stages, in which conclusion I am inclined to concur. 
The psychical symptoms are present in every case, though delirium is not 
so common among very young children, and when it does occur is followed 
by a state of semi-consciousness, and finally by coma. The patients will 
not speak, but rebel against food and interference of any kind, and after 
a time it is very difficult to arouse them. One very interesting fact is 
that the coma is never sudden, but is preceded in every instance by either 
somnolence or delirium of the muttering variety. The coma sometimes 
becomes less profound in character, and there may be a lucid interval be- 
fore death. Motorial Disturbances. — The eyes are nearly always affected ; 
and the ocular trouble is either strabismus, ptosis, or a pupillary change. 
The former is an early symptom, and is probably the first indication of 
paralysis of any kind, and is seen most perfectly when a patient is awa- 
kened or aroused. The pupils are sometimes unequally dilated, but when 
the coma supervenes dilatation is complete ; pupillary changes are, how- 
ever, by no means constant. 

Unilateral paralysis is not rare ; some of the facial muscles being alone 
affected, or there may be extensive hemiplegia, which is an advanced 
symptom. Spastic contractions are evidences of a condition of central 
irritability ; and rigid flexion of the muscles of the thumb, or muscles 
of the sub-occipital region, are examples of this kind. The patient 
commonly lies with his thumbs drawn into the palm of the hand 
and covered by the fingers, and it is sometimes difficult to open the 
hands. 

I have alluded to convulsions, and in addition may say, that they are 
more prominent in the first four days, and vary in severity if the coma 
be either very deep or there is a condition of semi-consciousness. In the 
latter case they may involve isolated groups of muscles. 

OphthalmoscopiG Signs. — Bouchut,^ Galezowski,^ and numerous observ- 
ers have called attention to the value of the ophthalmoscope as an in- 
strument for diagnosis in tubercular meningitis. The latter has found 

1 Jahrbuch fiir Kinderheilkunde, B. 9, H. 3. 

2 Da Diagnostic des Maladies da Systenae nerveux par rOphthalmoscope. Paris, 
1866. 

3 Arch. Gdn., 1867, vol. ii. p. 262. 



ACUTE GRANULAR MENINGITIS. 63 

two forms of neuritis as evidecces of this disorder ; one a peri-neuritis,, 
and the other an inflammation of the optic nerve itself. Whiteness 
about the papilla, deposits of granular matter in the choroid, and tortu- 
osity of the retinal vessels, are appearances which have been described 
by others. FrankeP and Steffen found tubercle in the choroid some 
weeks before the invasion of the disease ; and Broadbent,^ in examining 
the fundus, discovered that the optic disks were dusky red, and mottled 
by white spots ; and the retinal veins were enlarged, while the arteries 
were very small. Tubercular meningitis of the convexity rarely presents 
ophthalmoscopic signs, though every form of convexity disease may 
occasionally give rise to retinal trouble. 

ACUTE GRANULAR MENINGITIS OF THE CONVEXITY. 

In the table I presented when speaking of the basal division of this 
disease, I mentioned the prominent symptoms of this variety. When I 
add that delirium and other decided psychical symptoms are highly 
characteristic of inflammation of the vertical region, I have described 
the difference between the two forms. This variety runs its course 
in a much shorter time, death generally resulting in from a week to ten 
days. 

When the malady (either basal or vertical) occurs in conjunction with 
certain tubercular affections of the lungs or peritoneum, there are local 
symptoms which precede those of the meningeal disorder, but the inva- 
sion of the disease is often very sudden. Constipation, followed by a ty- 
phoid state and drowsiness, are the precursors of meningitis when ante- 
cedent lung disease has existed. Not only may children be subject to this 
disease, but adults are as well ; and we sometimes find it as a sequence of 
various zymotic diseases, typhus or typhoid, remittent and other fevers, as 
well as pulmonary tuberculosis. A marked elevation of the evening tem- 
perature, incomplete hemiplegia, vomiting, or convulsions, are the promi- 
nent features of such a termination. Strabismus, unequal mydriasis, high 
pulse, and temperature, with some of the other symptoms which charac- 
terized the disease in the child, that have already been described, are 
generally present. 

It is sometimes so insidious in its approach and development as to 
puzzle the observer. The phthisical patient may become listless, drowsy, 
or complain of headache. He often wanders and gives way to a mild 
form of delirium, which appears during the latter part of the day. 
This complication may occur during the early stages of the pulmonary 
affection. 

Causes. — The question of diathesis naturally arises before any other, 
and we are immediately puzzled, for on one side we find that Rokitansky, 

1 Virchow's Jahresbericht, 1869, p. 621. 

2 Trans, of London Pathological Society, vol. xxiii. p. 216. 



64 



DISEASES OF THE CEREBRAL MENINGES. 



Kobin, Empis, Clark, and others consider the disease not to be directly 
connected with the tuberculous diathesis, and they go so far as to ques- 
tion the identity of the granular deposit in the brain with tubercle ; 
while arrayed against them are Rilliet and Barthez, Grisolle, and a host of 
others who are equally positive that it is in every case an expression of 
tuberculosis. Leaving the discussion, which is by no means settled, as 
the nature of the deposit needs much more investigation than it has re- 
ceived, we may assume that the affection is usually associated with a 
" scrofulous " cachexia ; that it appears among children who are badly 
nourished, and in whom the nervous diathesis is well developed. That 
exposure, insufficient food, and various exciting causes, such as dentition 
and over-study, produce it, no one will, I think, deny. In some in- 
stances — and these are by no means few — it is impossible to find any 
hereditary tuberculous history. As to age, we may consider that the 
so-called primary tubercular meningitis rarely occurs after the fourteenth 
year, and it is probable that a great many of such cases are unattended 
by tubercle, but by a granular deposit of simple character ; and primary 
tubercular meningitis in after life is, I think, a genuine tubercular disease. 

Watson^ makes the statement that fifty children are attacked within 
the first five months of life to every one after that time. I have found 
it to be more common after the first year, between the first dentition and 
the fifth year, though general practitioners who see more of these cases 
undoubtedly find them before that time. In large cities the mortality is 
undoubtedly greatest in the summer months, when diarrhoeal as well as 
other diseases and high temperature are conducive to its development. 
In the year 1871, in the city of New York, 84 deaths from " tubercular 
meningitis " (the reported exciting cause being "teething ") are recorded 
in the Health Board Reports, and the greatest number were found be- 
tween the sixth and fourteenth years,' a fact which seems to be irre- 
concilable with the statement that it is generally connected with the first 
dentition.^ 

The table presented below demonstrates that males are much more 
frequently affected than females, and of 169 deaths 91 were of males and 

^ Practice of Physic, p. 270. 

2 An inspection of the table prepared by Dr. C. P. Kussell, in the report of the 
Board of Health of the City of New York for 1870, will enable the reader to per- 
ceive the preponderance of mortality before the second year of life. 



Nativity. 
























U.S. 


For'n. 


Color- 
ed. 


Under 
Year. 


1 


2 


3 


4 


5 


10 


15 


20 


2,5 


M. 


P. 


M. 


F. 


M. 


F. 


M. 


F 


M. 


F. 


M. 


F. 


M. 


F. 


M. 


F. 


M. 


F. 


M. 


F. 


M. 


F. 


M. 


F. 


M. 


F. 


82 


76 


9 


2 






30 


28 


17 


21 


14 


9 


8 


5 


4 


7 


7 


3 


4 


4 








1 . . 


•• 



Also five males of 30, one of 50, and one of 55 ; this cause of death was .62 per 
cent, of the combined cause. 



ACUTE GRANULAR MENINGITIS. 65 

78 of females. Bertalot, already referred to, found that of his 24 cases 
fourteen were boys and ten were girls. Two cases occurred in the first 
year of life, seven in the second, five in the third, three in the fourth, 
three in the twelfth, and one each in the fifth, ninth, tenth, and fourteenth 
years. The youngest patient was ten weeks old, and twenty-two out of the 
twenty four were attacked between November and the end of June. The 
children were all more or less delicate, they had frequently grown up 
under bad hygienic conditions, and were generally scrofulous or scrofulo- 
rachitic In twelve there was a distinct hereditary predisposition to 
tuberculosis ; two cases supervened upon chronic coxitis ; one upon trau- 
matic erysipelas ; two upon pertussis ; one upon measles ; and one upon 
the first signs of dentition. 

There are certain physical appearances belonging to children predis- 
posed to these forms of disease which should not be passed unnoticed. 
In nearly all of the cases I have seen the head of the subject was pecu- 
liarly long and large. The hair was usually silky and fine, and of light 
color, and in some cases hip disease and like troubles had been noted. 

Morbid Anatomy and Pathology. — From the immense mass 
of confused testimony before us (for the disease has been described by 
nearly every writer, since the time of Hippocrates), it is extremely diffi- 
cult to say whether the post-mortem appearances are always those of a 
tuberculous character, or whether the granular substance is non-tubercu- 
lous, or again whether in some cases there is tuberculous deposit and in 
others simple granular collections. Paisley, who, Watson says, was the 
first to clearly describe the afiection without saying much about its tuber- 
culous nature, has given us a very admirable collection of facts bearing 
upon its morbid anatomy. 

Gerhard,^ one of the early medical writers of this country, says : " It 
was not known, previously to the researches of Dr. Kufz and myself, that 
the tuberculous character of the disease was anything but a mere compli- 
cation." Guersent, Dance, Hennis, Greene, and others shared in Ger- 
hard's opinion, that tubercular meningitis was a " strumous" disease. 

Rufz^ collected 40 cases, and in every instance there was complicating 
pulmonary tuberculosis. 

Fenwick's'^ tables are valuable in displaying the distribution of tubercle 
in the affection. 

In one of these, sixteen cases of meningitis occurring in tubercular 
patients are detailed in which tubercle was found in the lungs and other 
organs, but not in the brain. 

In these cases, of which ten were males and six females, there was tu- 
berculous deposit in the lungs in every instance, and in some of them 
other organs were affected. Positively nothing like tubercle could be 
found in the brain, but this organ was either congested or anaemic. The 



^ Dunglison's Prac. of Med., vol. ii. p. 243. 

2 Quoted by Marshall Hall, p. 94. 

^ St. George's Hosp. Keports, vol. vii. p. 35. 



bb DISEASES OF THE CEREBRAL MENINGES. 

membranes were " wet," and the ventricles contained fluid. Four cases 
were under ten years of age ; three between ten and twenty, and three 
between twenty and thirty ; four were in the fourth decade, and one in 
the fifth and sixth. In other cases brought forward by him of general 
tuberculosis, it was found that of fifty-four examined, nearly four-fifths of 
the number were below twenty-five years. All of these fifty-four had 
tuberculous deposits, both in the brain and other organs. 

The seat of the granular deposit seems to be chiefly the arachnoid and 
pia mater, though the dura mater has been found as well to be the site of 
granular accumulation. It is scattered mostly along the base of the brain 
and about the large arteries, where it may be found to consist of masses 
of little round pearly or yellowish bodies which may be almost as small 
as grains of coarse corn meal. The meningeal arteries are dotted over 
with these granules, and when the arachnoid is raised numerous under- 
lying miliary granules are exposed. 




Tuberculous Matter about the Yesselp. (Cornil and Ranvier.) — A. Tuberculous deposit. 
B. White blood-corpuscles. C. Granular contents of vessel. 

The membranes are all more or less congested and dotted with opaque 
spots or patches. The cortex is hypersemic and the ventricles distended 
by fluid. Their ependyma is toughened and rough, and presents a gran- 
ular appearance which may be likened to that of white shark's skin. 

Softening of various parts of the brain, the nerve trunks and optic 
commissure are not uncommon evidences of the violence of the disease. 
Patches of false membrane which contain in their meshes these granular 
bodies are scattered over the convexity and base, and render the removal 
of the brain or its menabranes separately a somewhat diflicult matter. The 
lungs, or other organs, may also present indications of tuberculous matter. 

Rendu ^ affirms that whenever there is paralysis of permanent form there 
must be some arterial obliteration from fibrinous exudation and consequent 
softening, and he does not believe that scattered granulations or ventricu- 
lar effusion are alone sufficient for its causation. 

^ Review in Gaz. des Hdpitaux, Jan. 15, 1873. 



ACUTE GEANULAR MEXIXGITIS. 67 

It is rarely possible to very closely localize limited deposits before death, 
but occasionally this may be done. 

A very interesting case is reported by Kaymond which presented seve- 
ral suggestive points. One was that the motor centre of the right arm 
was the seat of granular lesion, and that there was paralysis of that mem- 
ber. This, then, is an exception to the rule to which I have just referred. 

" The patient, a man twenty-two years of age, was admitted into the 
hospital in the early part of the month of January last, and then presented 
obvious symptoms of pulmonary tuberculosis, not, however, very pro- 
nounced. The affection, indeed, seemed to be progressing slowly. He 
was thin, pale, coughed a good deal, and was a little feverish. 

" On January 28 he began to complain of violent pain in the right hy- 
pochondrium, and two days later vomiting came on. This recurred fre- 
quently, the ejected matter having a greenish color. At the same time 
he suffered from severe headache, which affected chiefly the left side of 
the head. Fever then showed itself, the temperature rising to 140° ; the 
pulmonary lesions developed more rapidly, and the general condition be- 
came much worse. On March 24 he complained of great pain in his 
right arm, which seemed to be very heavy; at times he had great difficulty 
in moving it. On March 25 there were fresh pains in the arm, and motor 
paralysis was comjDlete, sensibility beiug retained. In the evening, with 
a great effort, he succeeded in raising his arm to his head. The paralysis 
of the arm, up to the time of his death, presented the character of inter- 
mitten ce. There never existed any trace of paralysis in the right leg nor 
in the left arm or leg. Perhaps there was a slight degree of loss of power 
in the bucco-labial muscle of the right side, and a slight deviation of the 
tongue to the left, but these symptoms were a little doubtful. In the 
whole case, there was nothing else comparable with the paralysis of the 
arm, which was indisputable. The patient died on April 4. 

"At the necropsy, far advanced tubercular lesions were revealed in the 
right lung, and the membranes of the brain were found to be the seat of 
tubercular granulations. These were found in the pia mater over the 
right lobe, and there they were disseminated aloug the parietal branch of 
the Sylvian fissure. On the left side, in addition to the tubercular granu- 
lations, there existed some meningitis with purulent deposits. The men- 
ingitis was, if it may be so said, circumscribed and localized on two con- 
volutions, the anterior and posterior marginal near the paracentral lobe. 
There the tubercular granulations were very numerous, and formed a sort 
of tumor. The pia mater, covered with pus, adhered closely to the sub- 
jacent cerebral tissue. In other parts, where there were granulations, 
there was no vestige of meniugitis. jSTo other cerebral lesions, foci of 
softening, or obliteration of capillaries, could be discovered. There was 
a small amount of fluid in the ventricles, but nothing to note in the spinal 
cord or nerves of the arm. 

"Such are the facts of this case, which may be summed up as follows: 
Motor paralysis of the right arm, somewhat intermittent in the sense that 
it was at times complete, and at other times less absolute; and to explain 
this paralysis no other lesion than the tubercular meningitis in the region 
of the motor centre of the arm."^ 

^ London Med. Record, July 15, 1876. Abstract from Le Progr^s Medical, April 
22, 1876. 



68 DISEASES OF THE CEREBRAL MENINGES. 

Landouzy has collected a large number of valuable cases, showing the 
possibility of localization sometimes in tubercular meningitis, and has pre- 
sented 43, in which partial convulsions predominated in 23 cases. In these 
the distribution was as follows : 

The face alone, once ; the face and arm, twice ; the face, arm, and leg, 
five times ; the arm alone, six times ; the arm and leg, eight ; the leg alone, 
once. 

^ In half of these cases the convulsions were limited, in some cases the 
partial convulsions were preceded by those of a general character. He was 
enabled to diagnose the seat of the trouble in all of these cases. 

Prognosis. — No inflammatory disease of the brain or its membranes 
is more serious or rapidly fatal than is this. The termination is in death in 
from two to three weeks, though very rarely recovery may take place be- 
fore the disease has gone beyond the period of invasion. The ophthal- 
moscope is of service at this time. If there be optic neuritis, and 
basilar meningitis is suspected, there is very little hope to be derived 
from such an examination ; if the child recovers, it will be with impaired 
intellect, epilepsy, or some other serious life-long trouble. 

An anonymous writer in the Gazette Medicale upon the treatment of 
tubercular meningitis, says that, in a practice of thirty years, he has seen 
between eighty and ninety cases, and during that time there were but two 
recoveries.^ Bierbaum^ has reported three recoveries. 

Diagnosis. — This disease may be mistaken at different stages for 
several other acute conditions, viz. : — 

A. Typhoid fever — typhus fever. 

B. Scarlet fever or smallpox. 

C. Pleurisy or pneumonia. 

D. Eccentric irritation, such as that produced by worms, etc. 

E. Other forms of meningitis. 

F. Exhaustion. 

G. Syphilis. 

A. Typhoid, in some of its forms, or typho-pneumonia, may resemble 
tubercular meningitis, either of the primary or secondary forms. This is 
especially the case when typhoid symptoms are added to those of phthisis. 
The irregular varieties of typhoid are attended by absence of diarrhoea, 
tympanites, and other abdominal symptoms. The eruption of typhoid may 
also resemble the tache cerebrale of this form of meningitis, but it is 
usually confined to the chest and abdomen, and is an early symptom. 
Typho-pneumonia may bear a close resemblance to secondary tubercular 
meningitis, and this is particularly the case if moist rales can be heard all 
over the chest, and there is some dullness at the apex ; certain points are 
to be borne in mind, however, that will put the diagnostician on his guard. 
Uncomplicated typhoid is a disease of longer duration, and the abdominal 

^ Contribution a I'etude des Convulsions, etc., Paris, 1876. 
2 Gazette Medicale, 1871, 412. 
2 Deutsche Kiinik, 1873, 184. 



ACUTE GRANULAR MENINGITIS. 69 

symptoms are usually marked. There is tenderness in the left iliac fossa, 
high evening temperature, nose-bleed, and usually slight head symptoms, 
which vary. The eruption fades away under pressure, instead of being 
produced by pressure or contact, as is the case in the meningeal difficulty, 
and the prodromal symptoms of typhoid are not nearly so marked as 
those of the other disease. 

Typhus fever may sometimes make the diagnosis exceedingly difficult ; 
for, as we know, its duration is about that of the tubercular trouble, and 
head symptoms are its marked feature. The general absence of pulmo- 
nary symptoms, the appearance of the dark rash, and the antecedents of 
the patient offer us guides. 

B. Scarlet fever, which sometimes begins with vomiting and early head 
symptoms, may puzzle the observer. The throat trouble, the early appear- 
ance of the eruption, the peculiar "strawberry tongue" which, as far as I 
am aware, is found in but two diseases, diphtheria and scarlet fever, and 
the high and continued elevation of temperature during the eruption, are 
sufficient to put the medical man upon the alert. 

Smallpox, without the eruption, may sometimes mislead us. The pro- 
dromal symptoms, pain in the back, vomiting, and headache, are different 
from the same symptoms in tubercular meningitis. They are more severe, 
and may immediately usher in coma. Bleeding from the nose and mouth 
I have witnessed in three patients. This form of smallpox is quite rare. 
In the course of nine years, during which. I was connected with the 
Health Department of the City of New York, I saw over one thousand 
cases of the disease, and I do not remember having encountered but ten 
or twelve cases of this terrible form of variola. These cases were all 
adults. If pronounced smallpox should suggest the other affection, it 
will be found that in two or three days any blush eruption (which could 
hardly be mistaken for the maculae of tubercular meningitis, which is a 
late symptom) will develop so that the characteristic vesicles may be 
seen. In both scarlet fever and smallpox the history of exposure often 
supplies the link. 

C. Pneumonia and pleurisy can only be mistaken when we neglect to 
take into account the chill, pain in the side, and physical signs. The latter 
disease may sometimes be supposed to exist ; for Gee has heard the fric- 
tion sound of pleurisy in tubercular meningitis. 

D. Reflex irritation from ascarides may produce many of the early 
symptoms which also indicate tubercular meningitis, and even convulsions 
may appear ; but, unlike the tubercular disease, there is no further pro- 
gress. The use of an anthelmintic will clear up the diagnosis, if we have 
reason to suspect these parasites. 

E. From simple meningitis we may distinguish the disease chiefly by 
the late appearance of the delirium. The patient lapses into unconscious- 
ness in the former disease in two or three days, while in tubercular menin- 
gitis the acute mental disturbance is not so immediate. Acute meningitis 
runs its course usually in a week. 

Various intracranial diseases may resemble at different times the dis- 



70 DISEASES OF THE CEREBRAL MENINGES. 

ease under consideration ; but as I propose to treat of these hereafter, it 
will be well to omit them here. 

F. Exhaustion. — The excitement aroused in England by the Penge 
case gives this part of the subject decided importance. It will be remem- 
bered that one Louis Staunton, with two accomplices, one of whom was 
his brother, and the other a woman with whom he was living upon 
terms of criminal intimacy, starved to death his wife, and that they 
all narrowly escaped capital punishment or transportation. The 
coroner's jury decided that the real cause of her death was starvation, 
while several distinguished medical men contended that she had died 
from tubercular meningitis, but did not deny that she had been neglected. 
The disputed points seemed to be, the rapid emaciation and great anae- 
mia of the tissues, as well as disappearance of subcutaneous fat. Her 
symptoms before death were drowsiness passing into coma, stertor, 
rigidity of one arm, and inequality of pupils. These symptoms appeared 
but shortly before death, and were supposed by Dr. Greenfield,^ who 
made a most sensible and convincing communication to the Lancet, not 
to account for starvation alone, but to be probably due to tubercular 
meningitis. 

Opposed to him are several observers Tamong them Virchow, who re- 
viewed the English testimony) who held that the great emaciation, loss 
of weight of the internal organs, emptiness of the cavities of the heart, 
and certain forms of congestion were clearly indicative of starvation. 
Greenfield proved, I think, that none of these appearances were suflicient 
in themselves for us to say definitely that they were due to starvation ; 
that they may often be a result of exhausting disease; that the congestion 
witnessed was an ordinary post-mortem appearance ; and finally that 
tubercle existed in the lungs and brain ; while in the latter there were found 
primary indications of softening as well as adhesion of the meninges. 

Gee calls attention to forms of wasting disease with profound emacia- 
tion which may closely simulate tubercular meningitis, but are connected 
with digestive derangements and malnutrition ; and Sir Wm. Gull, in 
one of the English hospital reports, brought forward some years ago, 
several cases of hysterical anorexia, with emaciation ; and in the pro- 
found form of cerebral ansemia there can be symptoms which may resem- 
ble some of those expressed in tubercular meningitis so greatly, as to 
possibly lead to an error in diagnosis. 

G. A case of cerebral syphilitic meningitis which closely resembled 
tubercular meningitis was reported by VV^ebber. There were decided pul- 
monary troubles, and the tache cerebral, but antecedent pain for one year, 
mental dulness, etc., and recovery under specific treatment cleared up 
the case. 

Treatment. — More can be done for the patient in the early stages 
than at any other time. Cod-liver-oil, phosphorus, a nitrogenous diet, and 
preparations of iodine are all of great service. The syrup of the iodide of 

1 London Lancet, Oct. 6, 1877. 



CHRONIC CEREBRAL MENINGITIS. 71 

iron is an excellent remedy in the earliest stages, if we recognize the sig- 
nificance of the somewhat irregular group of symptoms. The iodide of 
potassium has been by many used during later stages. FJeming^ reports 
a cure in the case of a girl two and a-half years old by large doses of the 
iodide, and the experience of others is also encouraging. Cold to the 
head and the bromides in the later stages are of greater benefit than any 
other remedies. Ergot has been successfully used by Gibney in one case 
of so-called tubercular meningitis. It should be administered in full doses 
often repeated. It will be found that a drachm may be given every three 
or four hours without producing any disagreeable effects, and when the 
disease is well developed I have been able to do more with this drug than 
any other, and am confident that a case of simple granular meningitis so 
treated by me was saved by its early and free administration. Gee recom- 
mends closure of the eyelids by adhesive plaster, should there be any 
ulceration of the cornea. Blistering, bleeding, and violent treatment of 
any kind are to be strongly condemned ; quiet and darkness should be in- 
sisted upon as early as possible, and over-solicitous friends should be ex- 
cluded from the sick-room. Food of a liquid form may be given by 
enemata, or by the mouth, using a syringe, and being careful in intro- 
ducing its point between the teeth. 

CHKONIC CEBEBKAL MENINGITIS. 

This comparatively rare disease, which may be either the result of acute 
meningitis, or develop idiopathically, or after head injury, is of slow ap- 
pearance and progress, and resembles several organic diseases of the 
brain proper, among them softening, general paralysis, and brain tumors. 

Symptoms. — One of the early symptoms, especially of the vertical 
variety, is headache, which varies in severity. It is of a dull character, 
and is seated in the top of the head, and is increased by any effort which 
augments the cerebral blood pressure. In certain cases there is loss of 
memory, and other mental symptoms, which resemble closely those of 
general paralysis of the insane ; and this mental impairment may ter- 
minate in dementia. Insanity is by no means a rare sequence of chronic 
meningitis, and may follow inconsiderable early symptoms. In an 
interesting paper from the pen of Mortimer Granville^ seventeen 
cases occurred which began with sunstroke. In all of these insanity, 
usually dementia, followed the original trouble. The vertical 
form is generally complicated with encephalitis and muscular para- 
lysis, as well as spasms and twitchings of either a limited group 
of muscles, or the arm and leg of one side. Tremor and sometimes con- 
vulsions occur after a short period, while after the involvement of the 
vertical cortical substance we may have marked motorial symptoms, 
such as paralysis with contractures. Paralysis of the bladder or sphinc- 
ter ani, takes place, so that the patient passes his urine and feces in 
an involuntary manner. The disease is generally progressive, and 
there is an increase in the number of convulsions. The mental decay 

1 British Med. Journal, 1871, p. 443. 
^" Brain" Partviii. 



72 DISEASES OF THE CEREBRAL MENINGES. 

advances rapidly, and the patient finally dies, at the end of a few months, 
in a comatose state. The basilar form of disease is much more interest- 
ing than that of which I have just spoken, the cranial nerves being more 
or less involved ; and symptoms of cranial paralysis of a progressive 
character form a distinguishing feature of the disease. Thus, in thirteen 
cases collected by Dr. Cross,^ of this city, the third nerve was paralyzed 
generally on the left side in nineteen instances, and in one case the third 
pair on both sides was affected. In nine of these cases strabismus was 
noted ; in five of which it was external and existed on the left side. The 
pupils were dilated in eight instances, and contracted once. Obscureness 
of vision was observed to be prominent in four cases, while ptosis existed 
in five, occurring once on both sides. Double vision was present in many 
cases. Blindness occurred once in the left eye, which was the result of 
suppurative choroiditis. In another instance there was loss of sight in 
both eyes. I may select four of Dr. Cross's cases, which represent very 
fully the course of the disease : — 

Case I. — A young man came to the clinic who was affected with ex- 
ternal strabismus, ptosis, and dilatation of the pupil of the left eye. He 
had a most intensely agonizing pain in the head, vertigo, frequent attacks 
of vomiting, and paresis, if not paralysis, of the arm and leg on the same 
side. He was treated with mercury and large doses of the iodide of po- 
tassium. In a short time the pain in his head disappeared, and after the 
lapse of a few weeks the paralysis was cured. Two or three months sub- 
sequently he reappeared, with a corresponding set of symptoms in the 
right eye, and the right half of the body, and with pain in his head as 
severe as during the previous attack. He was again treated with mercury 
and the iodide of potassium, when his symptoms again disappeared, and 
have not since returned. In this case there was some slight suspicion of 
syphilis. 

Case II. — A man, twenty-eight years of age, came under my charge 
some two years ago. At that time he was suffering from pain in the 
head, vertigo, dilatation of the pupil, external strabismus, double vision, 
numbness, and slight paralysis of the opposite side of the body. As far 
as I was able to discern, the ocular paralysis was confined to the left in- 
ternal rectus muscle. Until within a few months prior to his coming 
under my observation, he had apparently enjoyed excellent health, with 
the exception of a severe headache, from which he had suffered quite 
acutely. He stated that the disease with which he was afflicted had come 
on slowly, and gradually increased in degree. He acknowledged that 
he had had a hard chancre several years previously. 

Under the influence of large doses of the iodide of potassium, the symp- 
toms rapidly disappeared, and he has since had no return of the paralysis, 
although he afterwards experienced severe headache, which disappeared 
under treatment. I examined his retinse, but found no disease. 

Case III. — Shortly after this I was consulted in regard to the case oi 
a gentleman, thirty-five years old, who was suffering apparently from 
symptoms similar to those observed in the preceding case, with the excep- 
tion of the paresis of the extremities. He had well-marked head-symp- 

1 Psychological and Medico-Legal Journal, New Series, vol. ii. p. 220. 



CHRONIC CEREBRAL MEXINGITIS. 73 

toms and numbness, -whicli was limited to one side of the body, but the 
paralysis was confined exclusively .to the ocular muscles. His eyes had 
iDeen carefully examined by an eminent ophthalmic surgeon, who had 
informed him that they were healthy, and that his trouble was probably 
cerebral. He was a very robust man, and had apparently suffered from 
no severe disease until the beginning of his present trouble. On question- 
ing him closely, he stated that he had had syphilis twelve years ago, for 
which he had been carefully treated, and consequently considered himself 
cured. When I first saw him, the double vision had existed several 
months, 'and during that time had been almost constantly present. I did 
not treat this patient, and consequently do not know the result. 

Case IV. — A married gentleman, forty-one years of age, came under 
my care in 1873. He was descended from a family saturated with rheu- 
matism, and gout, and five of whom had died of paralysis. At this time 
he ^as suffering from myalgia, which I found to be located in the muscles 
of the chest and back. This condition lasted about three months, and 
then disappeared under treatment. He stated that prior to this time his 
health had been good. He had been temperate in his habits, and had 
never had acute articular rheumatism, gout, nor syphilis. In July, 1873, 
he first observed that the pupil of the right eye was much contracted. 
This was followed by headache, vertigo, and obscureness of vision. In 
December he came to my ofiice and informed me that his ocular troubles 
had increased. At that time his condition was as follows: He had a dull, 
heavy pain behind the ears, which seemed to extend along the base of 
the brain, and was at times throbbing in character. There was vertigo 
and indistinctness of vision, which he described as a blurring of objects ; 
his right pupil was extremely contracted, and did not respond to the 
stimulus of light. Far and near objects were very indistinct, and ap- 
peared to be one above the other. When he looked at the pavement it 
appeared to be raised above its natural position. There were double 
vision and sia^abismus. 

He kept his head constantly turned to the right and downwards, in 
order to bring the axes of his eyes parallel. All his organs were healthy, 
with the exception of his brain. There was apparently partial paralysis 
of the right internal rectus and right inferior oblique muscles. This 
gentleman was, by my advice, carefully examined by two eminent oph- 
thalmic surgeons of this city, both of whom were of the opinion that 
there was no disease of the eyes. An important point in this connection 
is the fact that this patient had been in the habit of using a magnifying 
glass with the affected eye to examiae the delicate jDarts of machinery, in 
order to see that they were properly constructed ; and this operation was 
conducted in a dark room, lasting several hours daily. I carefully ex- 
amined this patient's spinal cord (as I always do in all these cases), but 
found no indications whatever of spinal disease. I ordered him to take 
the iodide of potassium, in fifteen-grain doses, three times a day, well 
diluted in water, and to rapidly increase the amount ; but the first dose 
caused him such intense nausea and vomiting that he could not be in- 
duced to take it subsequently. He consequently ceased taking any 
medicine, and for some time he continued to grow worse, all his symptoms 
increasing in severity. He was obliged to give up his business, and has 
since passed most of his time in out-door exercise. 

The pupil of the right eye remained permanently contracted for several 
months. A short time since I met him, and he told me that he was about 



74 DISEASES OF THE CEREBRAL MENINGES. 

to resume his business, he had so nearly recovered. His pupil was still 
contracted, but not to the same degree that it was when he first came 
under my care a year ago. He now holds his head straight ; there is no 
apparent strabismus, although his wife informs me that he occasionally 
sees double. His headache and vertigo have disappeared. The only 
medicines that he has taken during this period have been tonics and 
out-door exercise. I made particular inquiry in this case, in order to 
discover, if possible, a constitutional cause, but I was fully satisfied that 
none existed. 

Both of these forms of meningitis may be connected with cerebral 
growths and syphilitic and tuberculous deposits. 

Causes. -rMales seem to be oftener afiected than females, and the 
disease is ordinarily one of adult life. It is connected oftentimes with 
the tuberculous diathesis, and is not rarely dependent upon constitu- 
tional- syphilis ; it may be seemingly idiopathic, or result from head 
injury, exposure to the sun, intemperance, the acute zymotic fevers, and 
the other causes of meningitis. 

Morbid Anatomy and Pathology. — The cerebral meninges 
have been found to be thickened, adherent to each other, or to the inner 
surface of the cranial bones, with efiusions beneath, which have under- 
gone partial organization ; sometimes gummy exudation of syphilitic 
origin will be found scattered over the surface of the brain, or calcareous 
plates of perhaps an inch in diameter will be found in the dura mater, 
such as 1 have already spoken of in chronic pachymeningitis. If the 
disease has involved the cortical substance of the brain, we may discover 
patches of softening of variable extent and depth, and perhaps superficial 
abscesses. At the base of the brain the meningitis is not generally so 
diifuse, but occurs in circumscribed spots, the cranial nerve 'trunks being 
generally softened and bound down by bands of new tissue. In a case of 
meningitis following sunstroke ^Granville found very interesting osseous 
changes. 

" Calvarium strongly adherent, the plates dense ; diploe obliterated ; 
membranes very vascular, thickened and adherent to the surface of the 
brain along the median fissure : this was found on separation to be 
caused by three or four bony plates, of the size of a sixpence, with small 
spiculse passing into the surface of the brain on the left side ; the brain 
was smaller than usual and weighed only forty-four ounces ; the gray 
matter was deficient, and the convolutions flattened and apparently not 
so numerous." 

In this case sunstroke was followed by headache, most intense on the 
left side of the head, difficulty of articulation, defective memory, and 
subsequent symptoms resembling those of general paresis. 

Diagnosis. — The form of meningitis of the convexity presents so 
many symptoms that are common to other brain diseases, that the matter 
of diagnosis is often very difficult, and it is impossible at times to deter- 

1 Brain, Oct. 1879, p. 314. 



CHRONIC CEREBRAL MENINGITIS. 75 

mine the nature of the patient's disease until after death. Meningitis of 
the base, however, is much more easily diagnosed. There are nearly 
always ophthalmoscopic appearances, which is rarely the case in the other 
form of disease and some one or all of the cranial nerves are paralyzed. 
The symptoms of tumor may counterfeit those of chronic basilar menin- 
gitis, but perhaps are more severe. If the disease be of a syphilitic 
character, the question of diagnosis is a puzzling one; for in some 
respects a condition which favors the formation of syphilitic tumor and 
chronic meningitis is the same, and occasionally these two diseases are 
found to coexist. 

Prognosis. — Should the disease be syphilitic, the prognosis is favora- 
ble, unless the trouble be of long standing, but, if it be the result of injury, 
recovery is less likely to take place ; should it follow the acute exanthe- 
matous fevers, there is very little hope. 

Treatment. — Our main reliance is in the free use of large doses of 
iodide of potassium, or in the employment of mercurials. Active counter- 
irritation and the use of blisters and cauterization may afford a great deal 
of relief. A saturated solution of the iodide of potassium may be ordered, 
and the patient should be directed to begin with a dose of ten drops three 
times a day, and gradually increase one drop with each dose until he 
takes a hundred drops or more during the twenty-four hours. 



CHAPTER II. 

DISEASES OF THE CEREBRUM AND CEREBELLUM. 

SYMPTOMATIC CEREBRAL HYPEREMIA. 

Synonyms. — Cerebral Congestion, temporary Cerebral Congestion 
{Andral). Hyperemie Cerebrale (i^r.). Hyperamie des Gehirns {Ger.~) 

Definition. — A condition characterized by an abnormal increase in 
the amount of blood contained in the cerebral vessels and expressed by 
symptoms which indicate pressure and irritation of the cerebral nerve 
cells ; such increase in blood pressure being the result usually of general 
bodily disease. 

Until a few years ago this trouble was considered as a form of organic 
cerebral disease, at least as a part of a morbid process terminating inevit- 
ably in softening or cerebral hemorrhage. Such is the treatment of the 
subject by ^Andral, ^Durand-Fardel, '^Calmiel and many others. Not- 
withstanding the fact that Andral describes a " temporary cerebral hy- 
persemia," the condition never received any extended notice until fifteen 
or twenty years ago. * Schmidt describes functional hypersemia and anae- 
mia in his Compendium ; and Jaccord, Hammond and others.since have 
clearly established a form of cerebral hypersemia which has not of neces- 
sity any connection with graver cerebral troubles. 

Before entering into the discussion of the affection, I desire to state that 
in very few cases do I consider cerebral hypersemia to be a distinct cerebra 
disease, but rather one form of expression of some general condition, and, 
for this reason, I prefer to use the designation symptomatic. The apo- 
plectiform variety originally described by Andral, and many years after- 
wards by Trousseau, is without doubt a result of vascular rupture, and 
should be classed under " cerebral hemorrhage." 

Symptomatic cerebral hyperaemia includes those varieties of increased 
cerebral blood pressure dependent usually upon diseases of the heart, liver 
or kidneys ; such, for instance, as the symptom described by Bright as 
" the effect of cerebral blood pressure with venous turgescence,'' either func- 
tional or organic, or upon any condition which impedes the return of 
venous blood from the head. 

^ Clinique Medicale. 

^Traites des Maladies-Tnflaramatoires du Cervean, tome 1, Paris, 1859. 
•''Traite du Ramollissement du Gerveau, Paris, 1843, p. 153. 
* Compendium der Nervenkrankheiten, Leipzig, 1869. 
76 



SYMPTOMATIC CEREBRAL HYPEREMIA. 77 

Two forms of cerebral hypersemia have been recognized by the majority of 
modern medical writers, one of them which is active and connected with for- 
cible arterial fluxion, and the other passive, and the result of some impedi- 
ment to the venous return. I prefer to adopt the terms sthenic and asthe- 
nic, as these expressions denote pathological conditions much more appro- 
priately than do those in common use. Either may exist in a modified 
degree as physiological states^ and it is often difiicult to make the dis- 
tinction between a normal process and a diseased condition ; but when 
the cerebral fulness is constant or increased to a serious extent, we 
may safely judge the condition to be pathological. The division of the 
disease expressed by the terms I have just mentioned, though adopted 
by most of the authorities on nervous diseases, is for some reasons unne- 
cessary. 

Both varieties may lead to accidents symptomatized by attacks of 
coma, accessions of convulsion, a low grade of paralysis, mental excite- 
ment, and other serious results. These differ only in their manner of 
appearance. In one, they are early and sthenic expressions, and are pro- 
duced by rapidly exerted and violent force ; and in the other their ad- 
vent is more slow, as they appear to be produced by a sluggish force or 
tardy impairment of cell function, though sudden accidents which embar- 
rass the venous return may make their appearance as immediately as 
those of the first variety. Stupor is more decidedly characteristic of the 
passive or asthenic variety, than that in which rapid dynamic arterial 
action takes place. In this, the second variety, there seems to be a dila- 
tation of the small vessels, a crowding out of the perivascular fluid, and 
consequent pressure of the distended vessels upon the hyaline membrane 
next to the cells, thus preventing the removal of effete material, and 
consequently impairing their normal action. 

Symptoms. — The symptoms of this condition, as I have stated, may 
vary from evidences of what seems to be but healthy physiological func- 
tion to those which are unmistakably grave pathological conditions; from 
simple throbbing of the temporal vessels and flushing of the face, to coma, 
convulsions, or mania. 

Generally the symptoms are not serious, and out of the many cases I 
have seen (and, by the way, a large number of these mild cases are met 
with in private practice) they are of a type which may be recognized at 
once. The patient calls attention to the following troubles : A sense of 
head-fulness with throbbing of the temporal arteries. He may inform us 
that his " head seems to be of unnatural size and great weight ; that he 
feels as if the skin covering the head is much too tight." He complains 
of tinnitus aurium, and is troubled by subjective sounds which he 
compares to the buzzing of bees, the ringing of bells, and the rushing 
of waters. 

There seems to be an extraordinary acuteness of all the senses. He 
may inform us that there are bright specks or motes which flit across the 
field of vision, and may say that bright light is painful, complaining of 
his inability to read fine print, because the letters seem to dance upon the 



78 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

page, and the words appear hazy and blurred. Diplopia and other visual 
troubles may annoy him. Sharp noises, harsh voices, and monotonous 
sounds seem to produce distress and discomfort. His head is hot ; and 
Rosenthal has found that the thermometer introduced into the external 
auditory meatus recorded a rise in temperature. He may have hallu- 
cinations, but is generally able to appreciate their unsubstantial charac- 
ter. He arises in the morning unrefreshed and uncomfortable, complain- 
ing of muscular weariness, but feels better towards the middle of the day. 
After his dinner, particularly if it has been a hearty one, the cerebral 
condition is aggravated. At night he finds it impossible to sleep, and he 
tosses to and fro, his head being hot and his extremities cold. The mind 
of the patient is preternatu rally active, and his brain seems filled with 
excited fancies and troubled thoughts — and at last he sleeps. This sleep, 
however, is not sound;, dreams of all kinds, or nightmare, keep him in a 
state of wretched semi-consciousness till the morning comes to find him 
utterly used up. With the patient, mental exertion is irksome, and study 
or concentration is disagreeable or impossible. There is headache or im- 
paired memory, thickness of speech, and various difficulties of articula- 
tion. He may substitute one word for another, even though it be one in 
common use and exceedingly familiar. 

The emotions are generally disturbed and altered. Irritability, over- 
sensitiveness, nervous excitement, and morbid exhilaration of spirits may 
make his conduct strange and unnatural to those about him ; while slight 
things seem to disturb and harass him. The attentions of friends, though 
they may be of the most considerate nature, are met with explosions of 
temper, and the patient avoids them and prefers solitude. In such indi- 
viduals in whom the condition has existed for some time, this mental 
change is striking. They are suspicious of their wives and best friends, 
and all sorts of eccentricities are indulged in. There may be a species 
of hysteria which prompts the individual to commit suicide, when he has 
no intention of doing anything of the kind. He may worry his friends by 
his capricious behaviour, and succeed in making every one about him 
miserable. Sometimes he takes violent exercise until completely ex- 
hausted, when wearied Nature asserts herself and sleep brings temporary 
relief. 

During the progress of the disease, cutaneous numbness or twitching of 
some of the muscles, or even paralysis, gives the condition a serious char- 
acter. The appearance of the patient is decidedly striking, and not to be 
mistaken. The face is red, the cheeks pufied and swollen, the eyes promi- 
nent, watery, and injected, and the conjunctivae quite red. He is anxious 
and excited, or, on the other hand, stupid. The sleepy expression is one 
of the most valuable objective symptoms. Occasionally, in the course of 
the disease, there is bleeding from the nose, which may temporarily re- 
lieve the patient. The hands and feet are usually blue and cold, and so 
remain. After a variable period, during which the patient has presented 
a number of these symptoms, he may suddenly, after a hearty meal, or 
violent exertion or some other exciting cause, suffer an incomplete loss of 



SYMPTOMATIC CEREBRAL HYPERiEMlA. 79 

consciousness/ which is generally of short duration, and from which he 
can be aroused in a few minutes. When spoken to he seems bewildered 
and confused, and takes but little notice of what is going on about him. 
There seems to be incomplete loss of muscular power, more confined to 
one side than to the other, and he is able when less dazed to make simple 
voluntary movements. He seems to be annoyed by any bright light that 
may be let into the room. His pupils are contracted usually, and respi- 
ration is labored, while circulation is uneven, there being an irregular 
pulse. At first the heart's action seems to stop altogether, but subse- 
quently it becomes quite energetic, and the pulse is bounding and full. 
If the attack be due to passive congestion, there may be a dilatation of 
the pupils, and the bloating and puffing of the face and fulness of the 
lips will be much more noticeable than when it is the result of the sthenic 
variety. During its continuance there is neither rigidity of the muscles 
nor stertorous breathing. The recovery is generally rapid, and after the 
attack there may may be some epistaxis and slight mental excitement. 

A form, which certain writers have called maniacal, may and does 
often occur without any of the characteristic symptoms of increased cere- 
bral blood pressure that I have described. It is the form Miluer Fother- 
gill has so admirably described,^ and characterizes usually the pathologi- 
cal condition, in which the nervous tissues attract an abnormal amount 
of blood to themselves. This variety is not necessarily connected with 
vascular excitement, suffusion of the face, etc. It results commonly from 
protracted intellectual labor and direct excitement, and the patients may 
be pale and bright-eyed, and active in all their movements. They are 
" high-strung," restless, and remarkably irritable, and at the same time 
are loquacious and voluble. Their thoughts and fancies seem crowded 
together, and are evidently originated much more rapidly than they can 
be expressed. " Sometimes their ideas seem to settle themselves around 
some prominent leading thought, the centre-piece of the rotatory chaos, 
while at other times there is mental excitement, with great volubility, on 
no subject in particular." The condition is one of exaltation, and there 
is a restlessness which is characteristic. 

There is rarely any forcible heart action, the pulse being normal, or, if 
changed at all, is simply small and irritable. This condition does not 
seem to be confined to any particular age, though in old people cerebral 
congestion is disposed to take this character. The mental features may 
be those of ordinary acute mania, and all the phases of psychical disturb- 
ance may be expressed at some time or other. Suicidal tendencies are 
sometimes present. A case of this kind is reported, where the individual, 
during an attack of congestive mania, cut his throat. The loss of blood 
relieved the cerebral fulness, and his reason returned, but too late to 
avert the consequences of the act. This condition is one of rapid produc- 
tion, and under prompt treatment may disappear. Embarrassment of 

^ These symptoms are, without doubt, due to small hemorrhages. 
^ West Riding Reports, art. Cerebral Hyperemia, vol. v. p. 171. 



80 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

speech may vary from simple awkwardness of articulation to decided 
aphasia/ The difficulty is rarely a serious or lasting one, and is relieved 
by appropriate treatment. 

As I have before remarked, the second variety is more apt to be asso- 
ciated with deep stupor, and recovery is less certain and rapid. 

There may, indeed, be a form in which profound stupor, stertor, and 
full hard pulse are present, and which is almost always fatal. This 
follows profound narcosis by alcohol or opium, and the death of the indi- 
vidual is preceded by involuntary discharge of feces and urine, and 
there is complete loss of voluntary muscular power. 

Before concluding the description of the condition, it may be well to 
call attention to a form which is chiefly confined to early life, and occurs 
in the course of other diseases, or it may exist uncomplicated. In many 
respects it resembles meningitis. It is characterized by elevation of tem- 
perature and other febrile symptoms, among them vomiting, flushed face, 
headache, broken sleep, twitching of the limbs, constipation, and wander- 
ing delirium. Convulsions occasionally occur, and the attack ends in 
deep sleep. Recovery is the rule, although the young brain is so delicate 
and the violence of congestive disease so excessive, that a passive condi- 
tion may take the place of, and remain after the acute condition, and 
death may ultimately follow. Epilepsy not rarely originates in this way. 
It cannot be doubted that mental worry causes cerebral congestion, and 
therefore accelerated action of the heart gives rise to contracted kid- 
ney and ursemic symptoms. 

Causes. — CalmeiP and others consider that men are far more subject 
to cerebral hypersemia than women, and I think clinical experience fully 
supports their views. Some occupations and vices of men are peculiarly 
apt to lead to disordered states of the circulation, while women, as it will 
be seen, are not affected nearly so often as the other sex, and generally 
suffer only at the menstrual periods or when there is a retarded flux. 
Andral calls attention to the symptoms complained of by women just 
before the time of the menstrual period — these are vertigo, flushing of 
the face, troubled respiration, flashes before the eyes, and other evidences 
which point to congestion of the brain. When the menses are irregular 
or suppressed these symptoms are more intense, but are promptly relieved 
by re-establishment of the flow. He relates the case of a man who 
every summer suffered from an acute train of symptoms indicative of 
softening, which subsided after he had had an hemorrhage from the bowels. 
There was no history of hemorrhoids. It is not confined to any age, but 
is commonly a condition of middle life, though special causes may influ- 
ence its origin at other periods. 

As to the etiological bearing of climate and temperature, there has been 
much discussion. As far back as the time of Hippocrates ^ we have been 

^ This grave form is probably due to some lesion, 

2 Maladies inflammatoire du Cerveau. 

3 Aphor., Lect. iii. 16, 23. 



SYMPTOMATIC CEREBRAL HYPEREMIA. 81 

told that it is a condition produced or aggravated by low temperature, in 
"which opinion he is sustained by Aretseus.^ Cheyne and others consider 
that extreme heat favors this morbid state, and Andral contends that the 
greater number of cases occur in cold weather. 

As far as my own experience is concerned, I have found, that either 
extreme heat, or cold, may develop the disease, but the greatest number of 
my cases have arisen from exposure to the direct rays of the sun, or have 
been among men whose avocation led them to pass their time in hot places. 
Bakers, sugar- refiners, furnace-men, glass-blowers, etc. etc, are often 
aifected, and it is hard to say whether these people or those who overuse 
their brains, form the largest number. I give below a table which details 
the occupation of 160 of my patients. 

One Hundred and Sixty Cases of Cerebral Hypercemia — Occupation. 

Bartenders, or Liquor Dealers . 18 Lawyers 16 

Bakers 15 Musicians 2 

Blacksmiths 19 Merchants 15 

Carpenters 3 Painters 2 

Carpet-cleaners 1 Physicians 6 

Foundrjmen 6 Printers 2 

Harness-makers 2 Keporters 4 

Jewellers 2 Tailors 1 

Seamstresses • • • 5 Teachers 13 

Laundresses 3 Miscellaneous 17 



Laborers 



160 



By this table it will be seen that 64 were individuals whose pursuits 
subjected them to exposure to heat, and 54 were among persons who were 
hard students, worried business men, and the like. 

Immediately after the heated term of 1872 I saw many patients whose 
cerebral condition was produced by the great heat; but the disease 
may be due in many instances to exposure and cold, or is at least greatly 
aggravated by low temperature. Perhaps a reason for this may be that 
in cold weather the cutaneous circulation is not so active as during the 
warmer season, when the sudorific apparatus requires a free capillary 
circulation, and for this reason there is a determination of blood to the 
surface. In cases of sunstroke, as we know, the skin is generally parched 
and dry. 

As to predisposing causes we may enumerate them as follows : The 
organization of the individual, the existence of other disease, his habits 
etc. Two classes of individuals may be the subjects of cerebral hypersemia. 
—those of the thick-set plethoric habit, which Reynolds calls the " lax- 
fibred constitution,'^ and those who are spare, well-knit, and of nervous 
temperament. These latter individuals have generally hard, rigid arteries, 
are past middle age, and are usually brain-workers. 

In those individuals who possess a well -developed arterial system, but 

^ Aretseus de Signi et Cans, morbd. d. lib. 1, c. 7. 



82 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

such configuration of the neck and head as to prevent venous return, there 
is a tendency to cerebral fulness. There are several morbid conditions 
which markedly influence the development of this state — malaria, renal 
and cardiac diseases, and syphilis being among the number. In patients 
with enlarged and diseased kidneys which are unable to excrete the effete 
nitrogenous waste from the blood, it remains in the circulation, increasing 
blood pressure, and necessitating excessive activity and rapidity of heart 
action. Hypertrophy of that organ is a result, and the walls of the right 
ventricle become greatly enlarged ; and having much greater force than it 
possesses in its normal condition, it forces the blood with great energy into 
the cerebral vessels, and as a result there is produced the morbid condition 
of which we have spoken. Pulmonary disease, attended by diminished 
aerating space, sometimes has the same influence. Gout may be at the 
origin of cerebral hypersemia ; and, as I have said, malaria very often plays 
a very important part in the etiology. 

Syphilis I have found to have much to do with cerebral hypersemia. In 
this disease this condition of the cerebral vessels is not uncommon during 
the secondary and tertiary stages, but more often during the latter. Four- 
nier has described a form of trouble produced by syphilis characterized 
by head-fulness, vertigo and attacks of unconsciousness of an apoplectiform 
nature, and^Chauvet thinks that such forms are but precursors of an 
inflammatory condition of the cerebral vessels, and that it is followed by 
narrowing of calibre and ansemia. Mental perturbation and hysteria 
seem to be connected with these forms. 

An excessive indulgence in alcohol, immoderate eating and drinking 
or the abuse of tobacco; continued venery, and disregard of the ordinary 
calls of nature, are all predisposing, and some of them exciting, causes. 
Protracted or unnatural intellectual labor, emotional disturbance, mental 
strain, and intense excitement of various kinds, are additional causes of 
great importance. 

Intellectual labor at night, particularly when there is- a gas-light above 
the head of the patient, or prolonged business worry, not rarely favors 
the determination of blood to the brain. Night editors, students, and 
workers by artificial light are subject to this condition, and eye-strain 
from these occupations is a powerful factor in the causation. 

Myopia and various errors of refraction and accommodation are some- 
times at the origin of severe headaches of the congestive variety. Pro- 
longed grief, especially when the patient neglects his bodily comfort, and 
passes long days in mourning, eating little, and gaining no sleep, is also 
a cause. The acute condition is not rare among nurses who have sat up 
at night ; and they, as well as other night-workers, are very apt to com- 
bat the disposition to sleep which is healthy, by stimulants, cofiee, or 
other agents, and after a short period a disagreeable state of congestion 
follows. 

^ These de Concours, 1880. Influence de la syphilis sur les maladie du systeme 
nerveux, p. 9. 



SYMPTOMATIC CEREBEAL HYPEREMIA. 83 

As distinct exciting causes I may mention alcoholic abuse — pressure 
made upon the veins of the neck by tight collars or other articles of dress 
— sudden exertion of any kind, such as straining at stool, or during child- 
birth, and lifting heavy weights. In one of my patients, the simple act 
of bending over to button his shoe was sufficient to produce an alarming 
condition of the cerebral circulation. In some persons the condition is 
aggravated, or attacks of the severer kind are precipitated by a visit to 
the theatre or some crowded place of amusement, where ventilation is bad 
and the room heated to a high temperature. 

Pathology.^ —Almost enough has been said to explain the changes 
which occur duriug the development of a morbid state of intra-cranial 
circulation. Fothergill intelligently divides the processes which may in- 
duce this condition as the following : 1. It may occur as a vascular form, 
with increased blood pressure, and be dependent upon extra-cranial agen- 
cies. 2. It may result from tissue alterations, in which the blood is at- 
tracted to the brain, or from toxic agents, when the two former modes 
are combined. 

Through the cerebral ventricular connection and the spaces in the 
arachnoid we have reservoirs for accumulation of the fluid, when the 
blood pressure is diminished, aud a loose and capacious receptacle in the 
spinal arachnoid sacs for containing this fluid when the blood pressure is 
above the average, so that the balance is generally preserved. When the 
harmony of this arrangement is disturbed, we may expect to find evi- 
dences of such inequality. 

Now the question of the extent to which the brain may be compressed 
without injury, is one which I think will bear more discussion than it has 
hitherto received. Not only are the present means for experimentation 

^ By far the most important and interesting part of the study of brain histology 
is the intricate and beautiful arrangement of the perivascular space discovered by 
Robin* and His, f and described by them as well as by Bastian, X Fothergill, and 
others. His demonstrates the existence of these small spaces which surrounded the 
vesssels, than which they were several times larger. He found them in greater 
numbers in the gray substance, and thought he discovered a communication between 
the spaces in the brain and cord and certain lymph-ducts in the pia mater. 

The office of these canals which loosely contain the vessels, with which they have 
no attachment, is a most important one; for, notwithstanding the fact that the force 
of blood (particularly that which goes to the cerebrum) is moderated by the tortu- 
ous course of the arteries after they enter the cranium, and their complete subdivision 
when they are distributed over the pia mater, the nervous substance would be little 
prepared without such an arrangement for sudden and violent accession of blood. 

This space or cavity about all of the vessels enables them to expand to a great ex- 
tent without any actual pressure being made upon the adjacent delicate tissues. 
When such a determination of blood occurs, the perivascular fluid is driven out of 
the nervous substance proper, and after the hypersemia subsides, returns to the spaces 
about the vessels. 



* Compte Rendu de la Soc. Biol., Paris 1855. 

t Zeitschrift fiir Wiss. Zoologie, Band 15. 

Notes to translation of His's paper, Journal of Anatomy, vol. 1. 



84 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

inadequate, but there are certain puzzling questions that come up in the 
most unexpected manner. The experiment of suspending the subject, 
constricting the vessels, and measuring the blood pressure by instruments 
devised for the purpose, has been tried. Dr. Loring ^ has related an in- 
stance where the first experiment was made, and I shall use his own words : 
" I would mention that a patient of mine, the acrobat known as the 
' Champion Fly Walker,' informed me that in walking across the ceiling 
of a theatre, head downwards, he never felt the slightest disturbance in 
his vision, though the feat occupied fifteen or twenty minutes. This 
would go to show, also, that position did not have so marked an influence 
on the quantity of either blood or serum in the interior of the head as is 
now believed to be the case. For it hardly seems possible that the quan- 
tity of blood could be either increased or diminished to any considerable 
degree, even at the expense of the other fluids, and yet allow one to main- 
tain for so long a time such a complete control over the faculties, espe- 
cially that of co-ordination, as to perform so dangerous a feat, and one 
which demanded so nice an application of the senses. Be this as it may, 
I must say I have never been able to see the great weight of Kellie's and 
Burrows' experiments with animals which were killed and then suspended 
by the head or heels, as the case might be." 

When an individual is thus suspended, we are furnished with all the 
external indications of cerebral hypersemia^the flushed face, prominent 
eyes, etc. — but consciousness is unimpaired, and is not lost until some 
time has elapsed. This question is of interest, for it suggests the idea that 
perhaps after all many changes in cerebral function are due to the 
shock sustained by nerve-cells by the sudden accession of blood, and not 
so much to the mechanical pressure exerted. ^ In a very carefully pre- 
pared article by Cappie in " Brain " upon the balance of pressure within 
the skull, it is shown that the atmospheric pressure is exerted upon the 
veins as they leave the various openings in the skull, thus opposing the 
sudden exit of blood. He also alludes to the interlacement of vessels in 
the pia mater and the process of compression recurring when some of 
these vessels become distended. It is not difficult to realize that as a 
rule under ordinary circumstances the cerebral blood pressure receives 
no very rude modifications. 

As to the value of other methods for studying the state of the cerebral 
circulation by gauges, watch-glasses luted into the skull, etc., I am rather 
sceptical. The cranial cavity is, of course, a closed cavity, and the 
blood supply of its contents is modified by the pressure of the bony wall. 
Any perforation must admit the external air, and the intra-cranial blood 
is then circulating under an atmospheric pressure, and I am strongly con- 
vinced such variations as have been described are not those that take 
m the normal state. 

I have said sufficient in detailing the causes of cerebral hyperaemia to 

^ Am. Psycholog. Journ., Nov. 1875. 
2 Brain, Part viii. 1879, p. 373. 



SYMPTOMATIC CEREBRAL HYPER.EMIA. 85 

explain any pathological processes, the description of ^-hich I may now 
pass over. 

Morbid Anatomy. — Upon removing the calvarium the observer of a 
fatal case will probably meet with some if not all of the following appear- 
ances. Dura mater and underlying membranes injected and pink, or opales- 
cent, and sometimes quite free from moisture, resembling in this respect a 
piece of damp sheepskin. The sinuses may be filled with dark blood, 
and the surface of the brain fiiattened and of a deeper color than normal. 
The convolutions may be flattened and pressed down so that the sulci 
are defined in sharp lines, the inner surface of the convolutions being 
pressed together. The surface of the brain, as I have said, is dark, and 
if the pia mater is torn ofi" fluid blood may escape from the separated 
vessels. Upon making sections in a transverse plane the observer will 
be sometimes struck by the appearance of a pinkish blush, visible in 
spots, which is due to staining by hsematoidin. This appearance, alluded 
to by Fox^ has been compared to spots of red sand dusted on the surface. 
The corpora striata are of a very deep red or even violet color, and the 
white matter contains small puncta which are red or dark purple. The 
vessels are generally enlarged, tortuous, and filled with quite dark blood. 
CalmeiP has presented the records of autopsies in a number of cases of 
temporary duration. He found " in three cases that the cranial bones 
were notably injected ; in three the vessels of the dura mater were con- 
gested ; in one case there was fibrinous coagulation in the longitudinal 
sinus ; in one the internal surface of the dura mater was furrowed by 
capillary arborizations ; in two the cavity of the arachnoid contained 
liquid blood and bloody humidity ; in four the cerebral pia mater was 
generally congested ; in three cases it was reddened by extravasated 
blood ; in one the pia mater adhered in spots to the subjacent convolu- 
tions ; in one these convolutions on the right side were swollen ; in four 
the cortical substance of the brain was generally injected and more or 
less colored by hsematosin," etc., etc. We therefore must arrive at the 
conclusion that there is nothing remarkably significant in regard to the 
seat of the congestion or its form. The violence of the symptoms will, of 
course, be proportionate to the extent of hypersemia, though this is not 
always the rule ; and I have seen cases, and I think others also have, in 
which profound coma and speedy death were preceded by unmistakable 
symptoms of hyperjemia, such as contraction of the pupils, etc, and after 
death very slight evidences of congestion were perceptible. Microscopical 
examination reveals in old cases a condition which has been called by 
various writers " I'Etat crible. This consists of a peculiar spongy, worm- 
eaten appearance. Arndt says that when these lymph-spaces are dilated 
they are filled with effete material from the brain resembling amyloid 
substance or leucin, called by him hyaline. The perivascular spaces are 
very large, and openings of some size are found at points where vessels 

^ Pathological Anatomy of Nervous Centres, p. 55. 
2Qaoted;bjrox, p. 56. 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



have been cut across. These are due to the abnormal pressure made by 
the distended vessel and the destruction of adjacent nervous tissue. Cal- 
meil, Van der Kolk, Durand-Fardel, and Irately Arndt/ have accounted 
for them as the result of oedema of the perivascular space. This appear- 
ance is a constant one in all brains where there has been continued 
hypersemia, and especially in the brains of drunkards. The bloodvessels, 

Fig. 13. 




Distended Perivascular Spaces, with Atrophy. (Fothergill.) 

when not destroyed, will be found to be tortuous and varicose, and coated 
oftentimes by a granular shining deposit. The pia mater is thickened, 
and its vessels present the appearance just described perhaps better than 
any other tissue. 

Diagnosis. — The condition in its early stages may be mistaken for 
the opposite state, cerebral anaemia ; in fact, the diagnosis is ahvays full 
of difficulties. 

An iospection of the following table may, however, furnish us with 
hints so that we may be enabled to separate cerebral congestion from 
cerebral ansemia. It will be observed that some of the symptoms are 
closely allied. 



CEREBRAL CONGESTION. 

Headache (generally diffused). 

Noises in the ears, generally " rum- 
bling,'' or singiug. 

Mental disturbance — loss of memory, 
hallucination. 

Pupils contracted. 

No heart sounds, except perhaps those 
of insufficiency. Pulse full. 

Urine not increased, generally con- 
tains urates and phosphates. 



CEREBRAL AN^^MIA. 

Headache (chiefly vertical). 

Noises in the ears (generally sharp or 
short). 

Mental disturbance — incapacity for 
mental work. 

Pupils dilated. * 

Pulse irritable, aortic murmurs, sphyg- 
mographic tracing almost straight. 

Urine passed in large quantities, is 
clear and limpid. 



Yirchow's Archiv. Ixiii. p. 24. 



SYMPTOMATIC CEREBKAL HYPEEiEMIA. 87 

In the apoplectic, convulsive, and paralytic forms there is little danger 
of making a mistake. 

These phenomena are sometimes liable to be mistaken for meningeal or 
cerebral hemorrhages, cerebral embolism or thrombosis, epilepsy, ursemic 
coma, etc. 

The apoplectic variety may be confused with cerebral or meningeal 
hemorrhage. When we bear in mind that in the former there is generally 
almost transitory loss of consciousness and motor power, that hemiplegia 
is not always present, and that marked stertor is rarely found, there is no 
room for a mistake in diagnosis. 

The other varieties of cerebral trouble, namely, embolism and throm- 
bosis, may be disposed of by calling to mind the sudden appearance of 
symptoms in the former ; its association with cardiac vegetations, and its 
permanent after-effects. 

A case of this kind presents itself to my mind. A gentleman, brought 
to me by Dr. Asch, of New York, had been told by some friend that his 
nervous symptoms were due to embolism. They were these: Three 
months before, while sitting in his studio, he lost consciousness, and fell 
over upon an unfinished picture. He was conscious of his condition, but 
could not help himself. The room became dark, and he " saw spots be- 
fore his eyes." He recovered himself in a few minutes, and resumed his 
work. A week ago a similar attack occurred as he was crossing the 
street, but he was unable to rise from the mud before assistance came. 
He had been worried by his business, had worked very hard, and had 
kept irregular hours. There was no aural disease. On neither occa- 
sion did the attack occur after a hearty meal. He had no heart symp- 
toms at all. After each attack he recovered when he took the needed 
rest, and then saw no evidence of permanent trouble. The suddenness 
of his attack suggested embolism, but as no paralysis nor aphasia fol- 
lowed, and no after-symptoms remained, it seemed out of the question 
to consider this his disease. I made the diagnosis of local cerebral hyper- 
semia. 

With embolism there is also generally pallor of the face, and absence 
of vascular excitement. 

Thrombosis is a disease of slow and steady progress, with well-marked 
symptoms, and finally decided hemiplegia. Aphasia is also a character- 
istic accompaniment of thrombosis as well as embolism. 

Cerebral softening can hardly be mistaken for the disease under con- 
sideration, because the former is nearly always preceded by partial cere- 
bral ansemia, or else some distinctly inflammatory trouble. In cerebral 
softening there is usually local pain. Convulsive movements, paralysis, 
and other decided indications mark the course of the softening. 

Ursemic coma may be distinguished by its deep character, and usually 
by an examination of the patient's urine. 

The epileptic attacks of cerebral congestion resemble those of true 
epilepsy very closely, and in many cases we must not be too positive. 
There is, however, rarely any disposition to sleep, and the attacks are 



88 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

generally preceded by some excitement, and are not ushered in by the 
cry. 

Prognosis. — The lighter form? of this morbid condition are usually 
amenable to treatment, at least this has been my own experience. Of 
course we must be governed by the duration of the disease, the existence 
of other affections of an organic nature, and the age of our patient. If 
he be over fifty his chances of ultimate recovery are bad, but if he has 
not passed middle life, and the condition is directly dependent upon some 
exciting cause that can be easily removed, we may express ourselves 
more cheerfully. The existence of calcareous vessels is not an agreeable 
circumstance, nor the fact that he has had previous attacks of an apo- 
plectic or paralytic nature. Perhaps the most grave prognosis is at- 
tached to the maniacal form in which the delirium is not violent nor 
noisy, but incessant and muttering, and in which there is a restlessness and 
desire for constant muscular exertion. The great danger seems to be in 
the continuance of the hypersemic condition, and the possibility of its 
termination in cerebral hemorrhage, meningitis, cerebritis, or other or- 
ganic afiections. With a hypertrophied ventricle and renal disease the 
patient has little to expect in the way of lasting relief, and we must always 
give in such cases a very guarded prognosis. 

Treatment. — Of course, the first indication, after inquiry into the 
patient's habits and mode of life, is to discover and remove the predispos- 
ing and exciting causes if possible. The next is to diminish blood pressure, 
and restore the lost equilibrium of the intracranial blood pressure both 
by local and general treatment. 

In the majority of cases, the most simple treatment, with attention paid 
to the patient's bad habits, wiU generally remove the condition. Absti- 
nence from alcohol in some cases, attention to the bowels, and the precau- 
tion of keeping the head cool and the neck unconfined, are the first obser- 
vances to be followed by the patient. 

If the condition be continued, or not relieved by these means, we may 
make use of several remedies, among them the bromides, ergot, and 
hydrobromic acid. The bromides, which were, I believe, first used for this 
purpose by Laycock, Clifibrd Albutt, and Drummond, promptly efiect a 
diminution in arterial tension and cerebral blood pressure. Max Schuler 
is of the opinion that they contract the small vessels, while Nothnagle 
thinks their chief action is upon the nerve cells. The bromide of sodium 
I consider the most potent of these salts, and in doses of twenty grains, 
three times a day, we may expect the best results. It is well to combine 
it with some cardiac sedative when there is tumultuous heart action, or 
with some heart tonic when there is a suspicion that the heart impulse is 
not sufiicient to properly drive the blood through the brain. Aconite in 
one case, or digitalis in the other, are good agents. If there be much ex- 
citement, and the mind of the individual be irritable, chloral may be 
advantageously administered either alone or with the bromides. 

Ergot or its aqueous extract is sometimes of great benefit in these 
cases. Dr. Kitchen has fully described its virtues, and my own experi- 



SYMPTOMATIC CEREBRAL HYPER^.MIA. 89 

ence is directly confirmatory of what lie has said. In doses of 3j three 
times a day, the fluid extract may be safely administered. Squibb's or 
Bonjean's watery extract, in five-grain doses, may be given alone or in 
combination with the bromides. Should the patient be very much de- 
bilitated, for this condition is often connected with general debility, 
we may give strychniss, phosphorus, iron, or quinine, though extreme 
care should be taken in deciding when they are useful or contraindicated. 

If our patient should not be able to bear iron, we may substitute either 
zinc or arsenic, the oxide of the former salt being most serviceable. In 
the forms where this treatment is required, viz., those where there seems 
to be a sluggishness of the circulating blood, it is well to dispense 
with bromides or ergot. 

During sudden attacks, local blood letting is advisable, leeches being 
applied to both ears, and cups over the mastoid processes. Cold to the 
upper part of the head, applied by means of a bladder or ice bag filled 
with cold water or powdered ice, isan important form of treatment. I 
direct my patients to apply cold to the back of the neck for fifteen 
minutes, every night and morning, and find that it succeeds admirably. 

A drug spoken of before is hydrobromic acid, which I have found to 
be a valuable and powerful ansemiant. 

^ I first advocated the use of a solution of hydrobromic acid in cerebral 
hypersemia some years ago. 

Dr. Fothergill in a subsequent article confirmed my views most fully, 
and I have since been gratified to find how my expectations were realized 
by a more extended use of the remedy. 

In small doses it acts very much as do the bromides, but with much 
more intensity. Half a drachm is fully equal to one drachm of the bro- 
mide of potassium. It differs, however, in the want of permanence of its 
effects, the bases of the bromic salts seeming to favor retention. 

With regard to diet, and indulgence in alcohol and tobacco, tea or cof- 
fee, it is impossible to lay down any arbitrary rules. I may begin, how- 
ever, by interdicting all the meats difficult of digestion, and recommend- 
ing a non-nitrogenous diet. Veal, corned-beef, pork, and certain vegeta- 
bles, such as cabbage, cauliflower ; or nuts, spices, bananas, and other 
aromatic or fatty substances, are not to be thought of. Simplicity of diet 
is to be insisted upon. Meats should be broiled, roasted, or baked ; and 
vegetables boiled. If the patient's comfort is dependent upon tea or cof- 
fee, it would be well to permit him to indulge in them to a reasonable ex- 
tent. I do not consider tobacco the dangerous agent that it is often said 
to be, and if the individual be a smoker, I think his after-dinner cigar need 
not be cut ofiT, and a glass or two of wine is not in the least harmful. 
Burgundy, Port, or other full-boiled wines should be given up as a matter 
of course. The abuse of alcohol and tobacco is to be looked after and 
stopped, if we have any reason to think that the patient has these bad 
habits. Open-air exercise ; cold baths, with friction ; or the Turkish bath, 
and other agents that tend to improve the cutaneous circulation, do a 

1 Philadelphia Medical Times, October 26, 1876. 



90 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

great deal of good, and are to be indulged in. We must insist upon the 
avoidance of excitement, dissipation, and late hours and theatre-going ; 
and it may be well to lay before our patient what may be the result of 
such imprudence. Should we be called in to find that the disease has 
manifested itself in either of the forms to which I have alluded (the 
apopletic, convulsive, paralytic, or maniacal), we must order perfect 
quiet, darken the room, and use every means in our power to reduce the 
cerebral blood pressure. 

CEKEBEAL HEMORRHAGE. 

Synonyms. — Apoplexy. Hsemorrhagia cerebria (Lat,). Apoplexie 
cerebrale ; hsematoencephalie ; coup de sang ; hsemorrhagie cerebrale 
(Fr.). Hirnapoplexieen, Schlagfuss (Ger.). 

Definition. — When through disease of a cerebral vessel its walls are 
unable to withstand the pressure of contained blood, a hemorrhage takes 
place, and the nervous substance in the neighborhood is subjected to pres- 
sure, the severity of the resulting symptoms depending upon the impor- 
tance of the parts which may be the seat of the accident, and upon the 
extent of the hemorrhage. 

Symptoms. — I have already alluded, when speaking of cerebral 
congestion, to light forms of hemiplegia of temporary duration, which 
were dependent upon slight hemorrhages resulting from cerebral conges- 
tion. We will now deal with a form of cerebral hemorrhage of a more 
serious character, and it may be stated that the brain is probably more 
liable to hemorrhage than any other organ, with the exception, perhaps, 
of the spleen. ^ 

Bastian has made the classification which I think it well to follow. 
He divides cerebral hemorrhage into three forms, in regard to the onset 
of symptoms : (1) The apoplectiform ; (2) the epileptiform ; (3) the 
simple, in which there is neither lo-s of consciousness, nor convulsions. 
The first may be considered as a sudden and profound loss of conscious- 
ness, which may or not disappear ; but, if it does, a certain amount 
of hemiplegia will remain. The epileptiform resembles the first, but, in 
addition to the coma, there are convulsions. As I have said, the simple 
variety may not be connected with any loss of consciousness, the patient, 
perhaps, awaking in the morning and finding himself deprived of power, 
or noticing such a loss when some movement is attempted. 

Prodromata. — Cerebral hemorrhage occurs generally in individuals in 
whom some well-developed chronic trouble has paved the way. This is 
the rule, although in many cases it may be the result of some recent dis- 
ease. When we come to speak of pathology and morbid anatomy, these 
general diseases, and their influence in the production of degeneration of 
the cerebral arteries will be discussed ; it is only necessary now to de- 
scribe the forms of expression of the preparatory stages. It is not always 

^ Bastian : Paralysis from Brain Disease, p. 14. * 



CEREBRAL HEMORRHAGE. 91 

necessary to look for the indications spoken of by HughliDgs Jackson/ 
*^The careful clinical observer consid'crs minor degenerative changes, 
baldness, grayness of hair, the state of skin, and worn teeth. He in- 
quires for the history of gout and intemperance." 

The appearance of those individuals in whom an apoplectic effusion 
may be looked for, may be of two kinds. 1. The thick-necked, red-faced, 
and full-blooded. 2. The fair, long-necked, or aged persons, in whom 
"the radial arteries are hard, and feel very much like strings of beads or 
pipe-stems beneath the skin. The existence of renal trouble also con- 
tributes to the development of an arterial state which favors rupture, 
and we should search for other indications of this trouble. Many of the 
symptoms of cerebral hypersemia may be precursors of those that follow 
cerebral hemorrhage. For several days the patient may have headache, 
formication at the extremities as if pins and needles were being thrust 
into the skin, perhaps a slight ansesthesia of the arm or leg of one side; 
his speech may be thick and clumsy, or he may drop a word here and 
there, and his eyes may be red and full of tears ; dizziness, muscse 
volitantes dependent upon retinal ischemia, and nose-bleed may all be 
indications of increased blood pressure. These last two forerunners of 
cerebral hemorrhage may recur at intervals for some time before the 
actual rupture of the vessel. The retinal trouble may be of long dura- 
tion, and is of decided importance as an evidence of the degenerate con- 
dition of the cerebral vessels, and should invariably be regarded with 
suspicion. An atrophy of the optic papillse with spots of blanching at 
the fundus, such as we find to be the result of Bright's disease, is also 
suggestive at times of a tendency to cerebral hemorrhage. To this list 
of prodromata may be added vomiting and stupor ; but these are con- 
nected with so many varieties of brain disease that they may only be con- 
sidered as important when occurring in conjunction with the trouble to 
which I have just alluded. A very serious premonitory symptom is paraly- 
sis of one limb or certain isolated muscles, which indicates organic dis- 
ease. After a variable time, during which some or all of these antece- 
dent symptoms may be observed, the vascular accident may occur. Its 
onset may take place in two ways : (a) In connection with profound 
loss of consciousness and suddenly. (6) Gradually, without loss of con- 
sciousness. We may call the first the apojylectie attack. Its common 
history is the following, and we may take as an illustrative case a male 
aged 50. The patient, who is of full habit, short, red-faced, and cor- 
pulent, had probably led a rather dissipated life. \Vliile reading his 
paper, after an unusually hearty dinner, he suddenly falls to the floor in 
an unconscious condition ; his breathing is stertorous, the cheeks and 
lips being jDufifed out by each expiration ; his face is dark, or perhaps 
very pale, the pupils dilated and insensible to light, and his eyeballs are 
fixed, turned upward, and drawn to one side. If the nostril be tickled 
no reflex movements follow, and the same is the case if the soles of the 

^ Cerebral Hemorrhage, " Keynolds' System of Medicine." 



92 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

feet be titillated. He is limp, and lies upon the floor in an inanimate 
heap ; the pulse will be found to be hard and full, but not very rapid, 
and if his temperature be taken it will be probably not exceed 97°, or 
perhaps is half a degree lower. He is taken up and placed in bed, and 
after a while may make some slight voluntary movement with the limbs 
of one side of the body. It will be seen that the others are without 
power, for if the leg or arm of the paralyzed side be lifted and released 
it will fall to the bed as a dead weight. After an hour or two, tickling 
of the sole of the unaffected foot will be followed by a drawing up of the 
sound leg. The eyes are still rolled up and turned away from the para- 
lyzed side of the body, and the edges of the irides are covered by the 
inner canthus of one palpebral commissure, and by the outer canthus of 
the other. The eyeballs may be sometimes slightly agitated by a feeble 
movement of a nystagmic character. It will be found, on removing the 
patient's clothing, that he has unconsciously voided his urine and feces. 
This condition may last for a few hours, the coma remaining profound, 
and the temperature rising to 103 to 105 degrees, and the pulse advanc- 
ing, when death takes place ; or it may be followed in an hour or two 
by slight signs of returning intelligence, an increase of temperature, say 
to 100°, with slight abatement of the regular respiration, disappearance 
of stertor, and the unnatural deviation of the eyes, when his temperature 
may return to the normal standard, and the patient so far recover con- 
sciousness as to be able to recognize those about him, and express him- 
self by simple words, as " yes " or " no." The urine has to be drawn 
for a day or two, and the bed-pan used, as the bladder and rectum are 
implicated. 

This form of cerebral hemorrhage may be connected with an epilepti- 
form attack in the beginning, and the convulsion may be either confined 
to one side or be general. It would be well, before going further, to 
dwell upon certain elements of the apoplectic attack and analyze the 
symptoms. 

THE PSYCHICAL DISTURBANCES. 

Sudden compression of the cerebral mass is always attended by uncon- 
sciousness, but it is a serious fact that slowly developed growths, such as 
large tumors or abscesses, seem to accommodate themselves to the sur- 
rounding tissues, so that sometimes no loss of consciousness occurs what- 
ever. I have seen a large abscess occupying an extensive tract of one 
hemisphere without producing the least loss of consciousness. The large 
effusions which produce unconsciousness are, in the opinion of Mr. Hutch- 
inson,^ productive of the psychical condition, by inducing anemia of other 
parts through sudden pressure. Small clots are undoubtedly productive 
of suspended consciousness, by cutting off either a large vessel, or by in- 
jury to some important sensory ganglion. 

Consciousness is either restored through the re-establishment of the 

^London Hospital Eeports, vol. iv., 1867. 



CEKEBRAL HEMORRHAGE. 93 

blood supply or the subsidence of shock, except where the hemorrhage 
has taken place in the medulla. The variation in the loss of conscious- 
ness is of great importance to the physician, especially in regard to prog- 
nosis. In severe cases there may be slight improvement in this respect. 
The patient's intelligence returns to such a degree as to inspire his friends 
with some degree of hope ; but there is often a sudden relapse to the ori- 
ginal state of coma, dependent upon fresh hemorrhage. 

RESPIRATORY DISTURBANCES. 

Stertor is an important symptom, and should always be looked upon 
with alarm. It is indicative generally of some lesion of the base, and 
nearly always lasts until death, if there be a very lai'ge effusion, but dis- 
appears after a few hours if recovery is to take place. Respiration un- 
dergoes very decided modification. Hughlings Jackson,^ in speaking of 
disturbed respiration, says : " Again, not only is the rate of respiration to 
be considered, but the character of the respiratory movements are to be 
noted. As they quicken in rate, so do they become more extensive in 
range though such respiration is still short. Thus in the first stage there 
may be only quiet action of the diaphragm, but at length the sides of the 
chest evert strongly in inspiration, the abdominal movement being less 
obvious, and at length the upper thorax takes part in the process. In 
severe cases the epigastrium sinks in during inspiration. This is proba- 
bly partly owing to elevation of the attachments of the diaphragm from 
increased action of the sides of the thorax, and partly to pushing down 
of the diaphragm by increasing bulk of the lungs from congestion or 
oedema " 

CONDITION OF THE EYES. 

Prevost,'-^ Vulpian, Lockhart Clark, and others were among the first to 
call attention to a peculiar diagnostic point which, though not always 
present, is of great value when it occurs. This has been known as " con- 
jugate deviation." During the apoplectic condition the eyes of the in- 
dividual will be fixed, so that they look upwards and outwards, towards 
the side of the lesion, and away from the paralyzed side of the body; the 
only exception being when the lesion is in or behind the pons. It is 
more often seen when the attacks are sudden, and it is a phenomenon of 
short duration, lasting at the most but a few days. During sleej) the 
condition subsides, and the eyeballs are restored to their normal state, 
but immediately on awaking they return to this position, and in spite of 
the patient's efibrt the axis of vision cannot be changed. When the ef- 
fusion is a large one, or when the onset is epileptiform, the pupils are at 
first very wildly dilated ; but when there exists a lesion in the pons the 
pupil which corresponds to the sides of the lesion is greatly contracted. 
Unequal dilatation, however, is not of very great diagnostic value. If a 
lesion in the pons be extensive, both are contracted. 

^ Op. cit., p. 548. 2 Gazette Hebdora., Oct. 13, 1865. 



94 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

TEMPERATURE AND PULSE. 

Thanks to Bourneville/ we are enabled to study systematically the 
variations of temperature. He divides the cases into four groups : 1. 
Copious cerebral hemorrhage, rapidly fatal, and attended by lowered tem- 
perature. 2. Cerebral hemorrhage, terminating fatally in from one to two 
days, in which the temperature is primarily lowered and afterward height- 
ened. 3. Fatal cases in which death takes place in from two to six days. 
In these, as in other forms, there is at first depressed temperature, next a 
return to the normal standard, with slight variations, and finally a decided 
rise. 4. Favorable cases, in which there are the primary lowering, a sec- 
ondary rise, and final return to the standard of health. 

These variations in temperature range between 96 and 108 degrees 
(rectal temperature). The pulse variation bears but slight rela- 
tion to the fluctuation of the body heat. In the four classes spoken 
of, we may consider in the first, that the pulse is full and slow, ranging 
from 55 to 65. With the rise of temperature which characterizes the 
others, it becomes greatly accelerated, beating oftentimes 120 to 130 per 
minute, losing its full character, and becoming small and irritable, and if 
death occurs, grows gradually weaker. If recovery follows the attack, 
there is a gradual return to its normal rate. Of course, this must be a 
very unsatisfactory consideration of the state of the pulse, for the apoplec- 
tic condition is not always the same, collapse and reaction varying greatly 
in regard to their occurrence and duration ; so the pulse, as well as respira- 
tion and temperature, undergoes many irregular modifications. 

ATTACKS V/ITHOUT LOSS OF CONSCIOUSNESS. 

The other form, in which the individual preserves his consciousness, is 
not so serious a condition as that just described. The person may present 
some of the premonitory symptoms already mentioned, or, on the other 
hand, may receive no warning, but while engaged in any ordinary occu- 
pation may suddenly find one-half of his body to be paralyzed, and be un- 
able to communicate with those about him, there being slight aphasia. 
With the paralysis there may be anaesthesia. This state of affairs may 
begin during the night, and on awakening in the morning he may find it 
impossible to leave his bed. The paralysis is sometimes gradual, the loss 
of power affecting one member, and afterwards the other, an unexpected 
feebleness being suddenly noticed as he is about to perform some act. One 
of my patients, an acrobat of dissolute habits, while preparing for the 
performance, found, when he attempted to put on his tights, that his right 
leg was quite powerless; he made an effort to stand, but became dizzy, 
and grasped for support a pole that was near. After repeated efiEbrts to 
dress he abandoned the attempt, summoned assistance, and was taken 
home ; the same night the right upper extremity was affected. He had 

1 Etudes cliniques et thermometriques sur les Maladies du Systerae nerveux. 
Paris, 1872. 



CEREBRAL HEMORRHAGE. 9o 

never had any previous vrarning. Attacks of this kind may be the fore- 
runners of others of a more serious nature. In illustration, may be men- 
tioned the case of"S. C, a married woman, aged 41. She was drawing 
water at a sink, when she became suddenly giddy, and had to take hold of 
the banisters to steady herself She stood thus until some friends put 
her into a chair and carried her to her room. She sat there that day, and 
was helped to bed, but did not discover her paralysis until next morning. 
Was not unconscious at any time of the attack. Her paralysis, when she 
discovered it, was somewhat worse than it is at present, and she could not 
speak as well as she now does. A few days after the attack she went to 
a hospital, where she remained one month. She entered the Epileptic 
Hospital July 6, 1875, and was put upon strychnine and belladonna, there 
existing an inability to retain her urine. I take the notes of her subse- 
quent history from the case-book of the hospital. 

^^ Sept 22. At 7.30 last night it was noticed that she could not speak as 
well as formerly. It was quite difficult for her to speak so as to be under- 
stood. She laughed a little immoderately at her inability to clearly enun- 
ciate the words. 

"An hour afterwards, in attempting to leave her bed, she fell, and since 
then has been scarcely able to speak, and can only say a few words. No 
other symptoms were noticed. Her strength of muscle and sensibility 
seems unaffected. She cries now continually, and seems to be depressed 
because she cannot speak. 

" Oct. 13. Patient can tell her name, and c^n name every article shown 
her. A little thickness in articulation. 

" Pupils react well. Lenses of eyes are a little opaque— the left a liitle 
more than the right. Face palsy almost passed away. Lower facial 
muscles act well. Sensibility in face fair. Tongue points slightly to the 
right. 

" Voluntary motion abolished in right upper extremity, the least motion 
in shoulder excepted. Articulations are all flexed in the right upper 
extremity, and the contracture is greatest in the hand, the fingers almost 
touching the palm. Elbow and shoulder are less rigid. 

" Extension is not painful, and there are no spontaneous pains in arm. 
Sensibility to contact in hand good. On finger tips feels the points of 
sesthesiometer at three millimetres. There is no numbness in hands. Pa- 
tient considers the paralyzed hand the warmer of the two. Between index 
finger and middle finger of right hand in three minutes' time the tempera- 
ture is 98 °. Same place on left hand in three minutes' time temperature 
is 98^°. Right lower extremity, no motion in toes and ankles, consider- 
able motion in knee and hips, no numbness, no contraction. 

THE RESIDUAL PARALYSIS. 

A paralysis, remaining after the " apoplectic stroke," is generally uni- 
lateral, though in rare cases, where the pons is affected at the central 
portion, the paralysis may exist on both sides of the body ; this one-sided 
paralysis is known as Hemiplegia, and may be complete or incomplete as 



96 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

regards sensation and motion. When we examine our patient after the 
immediate grave symptoms have to some degree subsided, we will find the 
limbs of one side limp, powerless, and generally without sensation ; the 
face paralyzed on the same side, and its other half drawn up by the healthy 
muscles, as their antagonists are unable to perform their functions. If the 
patient be sensible enough to put out his tongue, it will point to the para- 
lyzed side, while the eyes, if conjugate deviation exists, will turn in an 
opposite direction in a manner already described. 

Jastrowitz^ has called attention to a peculiar symptom, the tendency of 
the patient to slip out of bed on the unaffected side. This is caused by 
the inability of the paralyzed limb to support the weight of the sound 
part of the body. He also alludes to the fact, when pressure is made on 
the saphena nerve, at the point where the vastus externus makes a groove 
with the vastus internus, that the cremaster muscle on the paralyzed side 
will not draw up the testicle, which is not the case on the other side of 
the body. In other fornjs of paralysis, to be hereafter described, there is 
not the same uniformity of symptoms, there being perhaps paralysis of 
special cranial nerves, or those of the muscles of the face on the side op- 
posite to the body paralysis. This variety has been called cross paralysis. 
Both sides of the face or both sides of the body may be involved, in 
which event there is a speedy fatal termination. Occasionally the mus- 
cles of the pharynx may be paralyzed, and sometimes the larynx. A 
case of this latter kind is reported by Luys.'^ He mentions the case of 
" a woman who had a sudden attack of apoplexy with hemiplegia of the 
left side, but with no disturbance of sensibility or of the organs of special 
sense. The congestive phenomena of the onset being calmed little by 
little, the patient regained consciousness, and stated that four years 
previously she had been struck for the first time with left hemiplegia, and 
since then had been aphonic. Her intelligence was good, and she spoke 
distinctly, but in a low voice. She had no paralysis of the tongue, the 
soft palate, or the lips. A few days later, she was seized with new con- 
gestive symptoms, and died insensible." 

This laryngeal paralysis is undoubtedly a much more common affection 
than it is generally supposed to be, and the probability is that many of 
the cases reported as aphasic are in all probability aphonic. Our 
patient, after his return to consciousness, will then be found to be hemi- 
plegic, and, if he is amused and attempts to laugh, we will plainly notice 
facial distortion, which follows any such eflTorts. The surface temperature 
of the paralyzed parts is usually higher than on the other side, and the 
limbs may seem to be of greater contour, and true arthropathies may be 
presented. This appearance has been noticed by Hitzig," who, in refer- 
ring to Charcot's cases, presents seven of his own, in all of which there 
was incomplete dislocation of the head of the humerus, with irregular 

1 BerliiK-r Klin. Woch., Aug. 2, 1875. 

2 La France Medicale, Sept. 28, 1875. 
■^ Virchow's Archiv., xlviii., p. 345. 



CEEEBEAL HEMORRHAGE. 97 

pains of tlie arm, increased by pressure. The paralyzed arm was swollen, 
warmer and more moist than its fellow, and the pains alluded to began 
about six weeks after the apoplectic attack. Hitzig is of the opinion that 
this condition of affairs is not directly dependent upon the central lesion. 
Voluntary power is lost in proportion to the extent and situation of the 
lesion. Should it be in the cortex or corpus striatum, a very small lesion 
may produce very decided impairment of motility, while such is not the case 
in the white matter of the hemispheres. It will generally be found neces- 
sary to draw the patient's urine for a few days, for the bladder loses its 
expulsive force, and, if this procedure be not resorted to, there may be 
retention. Electric contractility seems to be exaggerated at first in the 
paralyzed limbs, and a very weak electric current may provoke the most 
energetic contractions. In certain cases there may be an increase of re- 
flex excitability and tactile sensibility. Sensations may be even some- 
times reversed, warmth being felt as cold, or vice versa, or, as in the case 
quoted by Bastian,^ a warm object may be appreciated as a weight. " A 
hot body on the face was recognized as pressure only ; on the arm it was 
felt as such, though the sensation was not distinctly localized, whilst on 
the left leg the same hot body was recognized correctly as regards situa- 
tion, though it gave rise only to a feeling of tingling." I have often 
witnessed hypersesthesia of the paralyzed limbs, which were very 
tender to the touch. An&esthesia generally exists, however, and electric 
sensibility is greatly diminished. At the end of a few days it is not un- 
common to find marked rigidity of the paralyzed limbs, increased reflex 
excitability, and other evidences of slight cerebritis at the seat of the 
clot. The tendon reflex is markedly increased in the paralyzed limb, and 
the slightest tap will evolve an energetic contraction. Gradually there 
is a return to the normal condition, and articulation, which was imper- 
fect in the beginning, may become more distinct, or, should there be 
aphasia, the patient will begin to command a greater number of expres- 
sions. A week or so passes, and he is able to protrude his tongue in a 
much straighter line than before, while the paralyzed muscles of the face 
slowly recover their lost power ; but when the levator palpebral is para- 
lyzed and ptosis results, restoration is much more slow. In regard to this 
paralysis, Bastian has reminded us that very often deformities exist, such 
as the absence of teeth on one side, which may produce an appearance of 
facial paralysis, when in reality none exists. This is seemingly a trivial 
matter, but its neglect is likely to lead to grave errors in diagnosis and 
prognosis. As months go by, gradual amelioration of the patient's con- 
dition takes place, the limbs regain their power, the leg first, and finally 
the arm, and the patient may be at first able to move his toes, then to 
raise his leg, and, when he leaves his bed, gradually begins to acquire 
power of locomotion. The walk of the hemiplegic is not to be mis- 
taken ; his gait is shufi[ling, the toe of the boot is dragged over the ground, 
and the leg thrown outwards and forwards, the knee being stiflT, and the 

1 Op. cit., p. 128. 



98 DISEASES CF THE CEREBRUM AND CEREBELLUM. 

arm swung helplessly by the side. As the gait improves, and the pa- 
tient gains more control over his limbs, he is able to perform movements 
which require the action of the muscles of the hip-joint, knee-joint, 
and finally the ankle and toes. Should he only partially recover, 
numerous secondary conditions may follow, as results of non-improvement 
of the cerebral condition. These are chiefly of a motorial character, and 
consist of spasms, permanent contractures, bed sores, atrophy, and in- 
flammations of nerve-trunks. Such sequela may be called — 

THE POST-PARALYTIC STATES. 

I may enumerate these as — 1. Permanent contractures ; 2. Trophic al- 
terations; 3. Tremor(post-paralyticchoreaof Mitchell and Charcot); and, 
4. Slow clonic spasms (so-called athetosis). 

Of 32 cases of old hemiplegia seen by Bouchard^ at La Salpetriere, in 
31 there were paralytic contractures. The other case presented what he 
called rhemijjlegie fiasqiie. This form is of slow appearance, and affected 
in the beginning the muscles of the forearm. The fingers were flexed, 
and the forearm was pronated and flexed on the arm, and at the same 
time the humerus was drawn to the trunk. 

According to Strauss,^ this form presents several variations, and some- 
times the hand is brought in contact with the trunk, either on its palmar, 
dorsal, or radial aspects. Of a large number of cases that have come 
under my observation, I have found that deformities of the upper extre- 
mities are much more common than of the lower ; the fingers are com- 
monly flexed and rarely extended, while the muscles of the trunk seem 
to be exempt from this change ; and, indeed, I cannot call to mind a 
single instance of this kind. Contractures of the muscles of the lower 
extremities are apt to produce deformities which resemble talipes, equinus 
varus or valgus, and the toes are flexed upon the sole. Contractures of 
the facial muscles are quite rare, and of late appearance. The deformi- 
ties are always quite striking, because of the antagonistic action of unaf- 
fected muscles, and usually no amount of force can overcome them. 
Trophic changes are by no means rare, either in connection with contrac- 
tured muscles or alone. I have now several patients under observation 
who are hemiplegic In one of these the skin of the paralyzed hand is 
white and puffed up ; the heads of the phalanges and metacarpal bones 
are reduced in size, so that there is no enlargement at their points of ar- 
ticulation, and a consequent depression exists. In other cases there is 
considerable muscular atrophy to be witnessed in the palm of the hand ; 
and in others the bones of the arm are greatly diminished in size, and the 
interossei quite wasted away. 

Charcot^ has written extensively about a form of neuritis following 
cerebral lesions, which is supposed to be of a central nature. That 
ascending (from the periphery to the centre) neuritis sometimes takes 

1 Des Contractures, Paris, 1875, p. 16. ^ Op. cit. 

3 Lemons sur les Maladies, etc. Fasc. 1, and previous articles. 



CEREBRAL HEMORRHAGE. 99 

place after cerebral hemorrhage there can be no manner of doubt; and in 
one case, at present under observation, the neuritis began at several dif- 
ferent peripheral points of the nerve, and there were consequent atrophic 
muscular changes.^ The form of neuritis, however, most deserving atten- 
tion is that known as secondary degeneration, described quite fully since 
the first edition of this book, especially by Flechsig, Charcot, and Bris- 
saud. It is pathologically the invasion of the motor tracts, which extend 
downwards involving the pyramidal parts of the lateral columns of the 
cord, and, as a result, we find beside loss of motor power, the appearance 
of contractures and an exaggeration of the tendinous reflex. The disor- 
ders of motility are numerous, and depend more or less upon the lost or 
impaired inhibitory power of the individual, and the paralyzed muscles 
which are their seat. 

Dr. Gowers^ presents the following excellent table, which embraces all 
the disturbances of motility which may occur after the hemiplegic 
attack : 

POST-HEMIPLEGIC DISORDERS OF MOVEMENT. 

[ Fine. 
r Tremor < 

( Coarse. 
C Regular (continuous, or on movement) J 

^ Certain, regular, move- 
I j ments, due to interos- 

Quick, clonic spasm, of j \^ sei, pronators, etc. 

r Ghoreoid f Continuous 
\ \ spasm, or 

Regular (continuous, or on movement) -l -< ineo-ordi- 



mtermittmg type. 



i I nation of 

V, Jerking v movement. 

r Continuous=" Athetosis " 
Slow, mobile spasm, of J 
remitting type 1 On movement =slow, cramp-like, inco- ^ 

i. ordination ("Spastic contracture " of 

r hemiplegic children. 
Tonic spasm, varying TOf interossei, conspicuous J 

Fixed rigidity, unvarying ^Offlexor-longus digitorum, conspicuous=late rigidity. 

The individual retains but little of his control over the affected muscles, 
though voluntary power exists usually to a variable extent The in- 
fluence of the will though often increases spasmodic movements. Spasms 
and tremor aflect first the smaller muscles, while tonic spasms afifeci; the 

^ These trophic muscular and cutaneous changes are of a most interesting nature 
Duncan* found in one case that an eruption had appeared on the thigh of the 
paralyzed side which disappeared with the return of power; and Charcot f and 
Payne J another. In a case mentioned by the former, a vesicular eruption appeared, 
which followed the distribution of the superficial ramifications of the peroneal nerve, 
and was coincident with the hemiplegia. In this case the hemiplegia followed em- 
bolism, and a branch of a spinal artery (rami medullse spinales, of Rudinger) was 
found obstructed by a plug. Pressure had been made on the spinal ganglion from 
which one of the branches of the sciatic originates. 

^Med. Chir. Trans., vol. lix. 



* Journ. of Cutaneous Med., Oct. 1868, p. 69 ; quoted by Charcot. 
t Op. cit., p. 72. J Br. Med. Journ., Aug. 1871. 



100 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

larger muscles of tlie limbs. One form of tremor of a post-hemiplegic 
character has been called by Mitchell " post-paralytic chorea ; " the tre- 
mor is suggestive of sclerosis, and may begin within a period ranging from 
one to several months, affecting generally the upper extremities, and it is 
aggravated by any exercise of volition. It may affect both extremities, 
but very rarely the face, and the movements are quite coarse, and may 
be associated with a certain amount of hemi-ansesthesia. A variety of 
movement of a clearly post-hemiplegic character has been elevated to a 
distinct position, and given the name "athetosis" by Hammond. As 
this condition is ordinarily a secondary affection to other neuroses as well 
as hemiplegia, the undue prominence which it has received is entirely 
undeserved. Gowers says : " Neither clinical history nor supposed 
pathology of athetosis affords ground for separating it from other forms 
of disordered movement commonly seen after hemiplegia, but any one of 
which might occur in the primary affection." Charcot^ refuses to ac- 
knowledge its distinct character. He presents several cases, all of which 
followed some form of hemiplegia ; and the literature of neurology is re- 
plete with examples of so-called athetosis which are generally connected 
with hemiplegia, chorea, or even hysteria. 

^ Brissaud has studied the particular features of the rigidity of late hemi- 
plegia, or, as he calls them, the "permanent contractures of hemiplegia," 
which are found to involve the flexor muscles. There are often what are 
called associated movements ; for instance, when one of his patients was told 
to firmly close her left hand forcibly it was found that the movement of 
flexion of this hand was always accompanied by slow movement of flexion 
of the right, moreover that when she opened and shut her left hand a 
number of times, the right became closed in the position of true con- 
tracture. This genesis of movements in the sound side is a feature of old 
contracture. 

The easy production of an increased tendinous reflex is always possible, 
and whether the tendons are lightly tapped or the member flexed or jarred 
there is a tetanoid state, or a series of spasms produced and the increased 
knee reflex commences, according to Brissaud, as soon as the appearance 
of secondary contracture begins. The myograph has been used to test the 
tendon reflex in hemiplegia. By the attachment of an ingenious instru- 
ment, constructed by Dr. F. Franck, it was possible to make some very val- 
uable records, showing the duration of the reflex, the amplitude of the con- 
traction and its character. ^Tochirjew and ^Burckhardt established the 
duration of the normal reflex at from 32 to 34-thousandths of a second, while 
Gowers believes the time to be longer. Brissaud has fixed the time at 
50-thousandths of a second, as that in which the reflex occurs in the nor- 
mal state. 

^ Op. cit., 4th part, p. 493. 

2 Recherches, etc., sur la Contracture permanente des hemiplegiques, E. Brissaud, 
Paris, 1880. 

^ Archiv. fur Psychiatric viii. Band 3 Heft. 

* Centralblatt far Med. Wissen, 1878, quoted by Brissaud. 



CEREBRAL HEMORRHAGE. 



101 



It would be going into the subject to the extent of neglecting those of 
greater importance were I to do else than present the conclusions drawn 
by modern observers. One of Brissaud's plates shows the contraction 
on the healthy and contracted sides. The upper irregular line gives the 
contraction, the lower line the time tracings, and the time of exci- 
tation. 









Fig. 


14. 








40 










1 

i 


1000 


-^ 




^== ^ 




1 
1 

1 



















Hemiplegia with contracture. Reflex on sound side. Time of reflex 40-thousandths. 
TRACINGS OF PATELLAR TENDON-REFLEX. 



Fig. 15. 




' ' I ' j'l.i.i ' h inTm I If N 1 1' ' I 'li 



1^ 



Hemiplegia with contracture. Affected side. Time of reflex 36-thousandths. 

Causes. — Any agency which favors a degeneration of cerebral vessels 
leads to the occurrence of hemorrhage such as I have just described. The 
list of such causes is therefore a long one. Among the many formidable 
diseases, leading to that which forms the present subject are those 
of the heart and kidneys. Hypertrophy of the left ventricle, Bright's 
disease, and local disease of the arteries with deposits of atheromatous mat- 
ter, or obliteration of vessels by softening, pressure made by tumors, and 
through other diseases of the brain, may be mentioned as influencing the 



102 DISEASES OP THE CEREBRUM AND CEREBELLUM. 

causation of cerebral hemorrhage. Cerebral hemorrhage is an affection of 
advanced life, though cases are on record among children. A careful 
inspection of the records of a great many cases discloses the fact that the 
majority are between fifty and sixty. With the advance of life and cor- 
responding impairment of vitality, the arteries become rigid, the heart hy- 
pertrophied, and the general vascular system undergoes important changes. 
I have already alluded to the annular and hard character of the arteries ; 
the arcus senilis, which consists of a small whitish circle which may be seen 
at the edge of the cornea, may be mentioned in addition as a suggestive 
sign, and attention may be called to the degeneration of the choroid. 
The color of the face is dusky red, and many of the capillaries of the skin 
covering the cheeks and nose are quite tortuous and dilated, and present 
minute varicose enlargements. As to inheritance of an apoplectic ten- 
dency, I fully agree with Hughlings Jackson, that the only heritage trans- 
mitted from father to son is the liability to arterial degeneration, gout, etc. 
This exception to the general rule is somewhat conspicuous, for the here- 
didon of many convulsive and neuralgic, as well as the trophic diseases, 
is a well-established fact, and has long been recognized as an important 
etiological factor. Cerebral hemorrhage, as I have stated, is by no means 
confined exclusively to adult life. Numerous observers have called atten- 
tion to cases which have occurred among very young children, though, 
in these instances, injury has generally produced the accident, especially 
such mechanical causes as convulsions, anaemia, etc. And now regarding 
the predisposing states which favor the rupture of a vessel. An hypertro- 
phied heart, enlarged by overwork in forcing the overloaded blood which 
must be formed when the kidneys do not properly act as eliminants, is the 
first factor of the disease. With this condition of affairs the small vessels 
must necessarily be subjected to abnormal strain, and consequently under- 
go such changes as thickening or aneurismal dilatation, or even actual 
destruction. The arterial changes, of which I will more fully speak when 
^Ne come to consider the pathology of the disease, are fatty degeneration, 
aneurismal dilatation, and calcification. These conditions are produced 
by alcohol, and improper diet, such as continued indulgence in fatty food. 
A sedentary life, connected with great and protracted intellectual strain, 
as well as such diseases as rheumatism, syphilis, and other chronic mala- 
dies, enter the field as predisposing causes. Season appears to have some 
influence in the production of cerebral hemorrhage, the majority of 
cases occurring in winter. As to exciting causes, their name is Legion. 
Straining at stool, coition, violent muscular effort of any kind, the indul- 
gence in stimulants, and in fact any agency which either promotes an ab- 
normal blood supply to the brain, or prevents its return, will have the 
effect, should there be disease of the vessels, of producing rupture. I 
have taken from my case-book data showing the causes in a number of 
cases, which in some cases preceded the actual hemorrhage by some hours: 

Lifting a heavy weight, or other muscular effort . . . . . .12 

Excitement (alarm of fire) 1 



CEREBRAL HEMORRHAGE. 103 

Violent exercise in drawing water 1 

Falls 4 

Fright 3 

Thrown down by husband 1 

Head injuries 8 

Straining at stool 2 

No history of cause 20 

52 

Time of Attach. — At night, in 30 cases ; during the day, in 22 cases. 

The fact that the large proportion of these attacks occur at night, is an 
interesting one. They were mostly hospital patients, and some were irre- 
sponsible ; so, of course, their statements are to be taken with allowance. 
One woman said : " I awoke in fright, and in attempting to rise found 
I was unable to do so." It is probable, therefore, that the condition was 
dependent upon disturbed cerebral circulation connected with nightmare ; 
nearly every one of these thirty patients found that they were j)aralyzed 
only when they awoke in the morning, and attempted to get out of bed. 
Exposure to the sun's rays, and the stoppage of any flux that is either 
normal or pathological, are often sufficient to produce an attack, and as 
an example of the latter hemorrhoidal bleeding may be mentioned. 

Hemiplegia may be a result of variola ; and the following case, in which 
epilepsy and hemiplegia dated from smallpox, possesses much interest. 
The paralysis was due undoubtedly to an epileptic seizure, during which 
some vessel was ruptured. 

M. J. T., 35 years, born in New York; no occupation; entered the 
Epileptic and Paralytic Hospital Feb. 11, 1870. Mother died of con- 
sumption ; sister had epilepsy. First fits appeared at the age of five years ; 
came on about three months after the attack cJf smallpox ; hemiplegia of 
the right side came on at the same time, she believes, as the epilepsy. 
Before the convulsions she had cramps in the paralyzed arm and hand, 
and a feeling of dizziness; the attacks occur most frequently in the day- 
time, three or four together, and recur once in three or four weeks. But 
shortly before her admission she had them nearly every day. Circum- 
ference of skull, 201 inches; antero-posterior measurement, 12 inches; 
transverse, 13 inches ; memory good, mind rather weak ; speech good, sight 
good, hearing fair with left ear ; cannot hear with right ear, even when 
the watch is pressed against it, Sensibility to pinching and pricking ap- 
pear entirely abolished on the right side from head to foot. Drags right 
leg in walking ; has but little use of right arm and hand, the muscles of 
which have a tendency to spasmodic contraction ; temperature somewhat 
diminished on right side ; appetite fair ; bowels rather costive. Menstru- 
ated at 13 years, and has been regular since. 

Present condition, June 1, 1876 : — 

Memory appears to be very good ; and the fits have decreased in seve- 
rity and in number. Had but two attacks last month ; none at night. 
Has haemoptysis sometimes before the attack, and an aura of about a 



104 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

minute's duration ; flexor of muscles of right hand is contracted : thumb 
is turned again, so that its inner part touches the under part of the index 
finger; lastly, the whole hand is somewhat drawn up, and lies in her lap 
with the palmar surface up. When directed to put hand up to shoulder, 
it shakes right and left ; this shaking is very violent, but only so when she 
makes voluntary movement. It is, however, entirely quiet while in her 
lap. Has the irregular hemiplegic gait ; protrudes her tongue straight ; 
eyesight good ; hears perfectly well. There is facial paralysis (periphe- 
ral) on the side opposite the hemiplegia, but no ptosis. 

As an illustration of a curious case of cerebral hemorrhage, Eulenburg ^ 
relates the case of a switch-tender who, during a heavy thunder storm, 
inserted an iron key in the lock of a switch signal. He was suddenly de- 
prived of power, and fell to the ground. After an hour or two, when 
sufficiently revived by the rain, he dragged himself to a neighboring sta- 
tion. He was paralyzed on the left side. 

Morbid Anatomy and Pathology. — A vessel impaired by disease, 
and subjected to even the normal blood pressure, will very soon sufier 
changes in its calibre, insignificant perhaps at first, but afterwards far 
more serious, but, when the blood pressure is abnormal, and a force is 
exerted which the resilient character of the vessels enables them to with- 
stand in the healthy state ; the weakened portion gives way, and the brain- 
substance in the neighborhood is subjected to dangerous pressure. The 
character of the loss of function depends very much upon the importance 
of the vessels and their areas of distribution. The middle cerebral artery 
is especially liable to rupture, being in direct communication with the 
left side of the heart; consequently, the corpus striatum, optic thalamus, 
and parts supplied by this artery, sufier injury. The other large vessels 
follow next, and may be aff'ected in various parts of their course. 

Such strides have been made in the study of cerebral anatomy and 
physiology during the past four or five years that it is necessary that the 
whole subject of nervous pathology should be viewed in a new light. 
New interest began with the researches of Jackson, Hitzig, Fritsch and 
Ferrier, and has since the discovery of the cortical centres been greatly 
increased by the valuable researches of Flechsig, Meynert, Huguenin, 
Charcot and a host of others. In the matter of central localization it 
behooves us to study the relations of the cortical psycho-motor centres 
and the so-called pyramidal tract comprising the descending fibres which 
run between the nuclei of the corpus striatum, and the optic thalamus, as 
the internal capsule, subsequently extending backwards and downwards 
as the peduncle (crus) and passing to the other side of the body, more 
or less fully in the pyramidal decussation. 

The sensory ganglia, and the fibres passing from thence downwards, 
and the connection of the bulb with the cerebrum, come in also for con- 
sideration. It will be only possible in this limited space to consider the 
anatomical relation and physiological functions of these parts so far as 
they concern the occurrence of lesions. 

1 Berliner Klin. Woch., April 26, 1875. 



CEEEBEAL HEMORHHAGE. 



105 



The cortex-cerebri has been found to be the seat of well limited 
centres, which when subjected to irritation from disease or mechanical 
injury, lose the function of localized sensory and motor innervating 
power. The gray matter of the cortical motor region is found to be 
peculiarly rich in large giant cells such as are met with in the anterior 
gray cornuse of the spinal cord, and by some authors are supposed to be 
identical with the latter. The more important of these centres are 
motor, and have been more or less appropriately called psycho-motor 
centres, and those of greatest significance are to be found upon either side 

Fig. 16. 




Cortical Centres. (Morel.) 



of the Rolandic fissure in the ascending parietal and frontal convolu- 
tions, and preside for the most part over the movements of the face and 
its parts and the limbs of the opposite side of the body. There are more 
posteriorly other centres which have a sensory function. At the angular 
gyrus (pli Courbe), for example, a visual centre is found which fills a 
prominent office in the regulation of visual correction, while other limited 
regions exist which undoubtedly play an important part as centres 
for the sense of audition, taste and smell. 

The excellent plate (Fig. 16) from Morel's Atlas will enable the 
reader to appreciate the action of the cortical centres. It is based upon 
the investigations of Ferrier. 

1 Speech centre of Broca. Posterior part of third frontal convolution. 

2. Centre for the movements of the upper extremities, situated on the 



106 DISEASES OP THE CEREBRUM AND CEREBELLUM. 

ascending frontal and parietal convolution circle (over the middle of the 
fissure of Rolando). 

3. Centre for the movements of the lower extremities. Situated at superior 
extremity of ascending parietal convolution. 

4. Centre for movements of head and neck. Over posterior extremity, 
or foot of superior frontal convolution. 

5. Centre for movements of lips. Posterior extremity, or foot of the 
middle frontal convolution. 

6. Centre for movements of eyes. Angular gyrus of parietal lobe. 
These are in the main the important psycho-motor centres, although 

they are capable of modification, and I would refer the reader for further 
details to Ferrier's admirable book. ^ 

The sensory centres, though more difficult to define, have occasionally 
been found to be the seat of disease, lesions being connected with 
limited loss of function. The centre of vision may be located in the 
supra-marginal lobule and angular gyrus in proximity to that centre 
concerned in the movements of the eyes, though it should not be con- 
founded with an anterior centre situated upon the superior and middle 
frontal convolutions, which control lateral movement of the eyes and 
dilation of pupils. 

The centre for hearing is located in the superior temper o-sphenoidal 
convolution. The centre for smell has been found by Ferrier in the 
subiculum cornua Ammonis, and irritation of this region is associated 
with some closure of the nostrils. The centre of taste is supposed by this 
author to be located in close proximity to the last mentioned centre. 
Many hundred observations have been collected by Charcot and Lan- 
douzy, Pitres, Seguin and a host of foreign and American observers, and 
most of them have a bearing confirmatory upon this theory, although it 
must be confessed that the large majority of collected cases present mul- 
tiple or extensive lesions, which too often cloud the diagnosis. The 
published cases prove in several ways, and first that cortical alterations 
in places found by experiment not to be the seat of psycho-motor 
centres are not followed by hemiplegia, and this is shown by the cases of 
Pitres. ^ Two cases are presented by Pitres, one of softening of the 
iuferior parietal lobule and sphenoidal convolutions, and the other of 
abscesses of the occipital lobe without hemij^legia. while other cases 
brought forward by him show the connection of hemiplegia with 
cortical softening of the ascending parietal convolution on one side, and 
aphasia with destruction of the third frontal convolution. 

In cases where autopsies have been made it ha^ been found that a de- 
generation of the motor fibres passing from this area of cortical centres 
had commonly taken place, and that such ''secondary degeneration" 
had extended down into the cord involving certain parts of the lateral 
columns, to be alluded to hereafter, and this secondary trouble was 

^ The Functions of the Brain. London, 1876. 

^Progres Medicale, August 7, 1880, and Eevue Mensuelle. 



CEREBRAL HEMORRHAGE. 



107 



found in some cases disconnected from any special lesion of the so-called 
motor ganglia, at the base of the brain, proving beyond doubt that the 
cortical psycho motor zone was that primarily affected. 

The disturbances of motility observed in connection with such cortical 
degeneration have been found to be of two kinds, spasm and paralysis 
existing together or apart, the latter being but an extended stage of the 
former ; and the interesting series of cases originally brought forward by 
Hughlings Jackson, who may be said to be the father of central localiza- 
tion, give to the matter an importance it really never has had accorded 
to it. It is the opinion of both Jackson and Brown-Sequard, both of 
whom have never been inclined to look upon the subject in anything 
like a narrow way, that the psycho-motor centres are not confined alone 
to the cortex, but exist throughout the brain as a complex system. 

My own experience has led me to adopt this view, especially as I have 
seen cases in which the cortical centres of Ferrier were involved and in 
which the only disturbances of motility were hyperkinetic, such as 
localized spasms; and it would seem to me that the destruction of the cor- 
tical centres resulted more often in an interruption of inhibitory control 
than in intrinsic and primiry abolition of motor power. There are 
numerous cases of cortical epilepsy in which no paralysis occurs, al- 
though the limitation of spasm to the member innervated by its particular 
cortical centre should always suggest the diagnosis. The occurrence of 
spasm in a monoplegic limb, that is to say a limb the seat of paralysis 
other parts being unaffected, is pretty certain to bear evidence of degenera- 
tion of a particular convolution. 




(Charcot.) 

When a large extent of cortical territory is destroyed we find a pecu- 
liar and extensive degeneration, which takes a well-defined downward 
course, as may be seen from reference to Charcot's admirable plate 
(Fig. 17). The zone which includes the psycho-motor centres 
above, and the inferior motor tracts, may be shown by a vertical cut 
which separates the hemispheres. A. represents the caudate nucleus ; 



108 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

B, the lenticular nucleus ; C, the ojptic thalamus, while between them 
passes the collection of fibres known as the internal capsule. The rela- 
tion of the nervous tracts with the convolutions above and the basal 
ganglia below is also shown in the diagram. D represents the para- 
central lobe, which has been found to be the most important psycho- 
motor region ; E, the ascending frontal convolution ; F, the ascending 
parietal ; G, the fissure of Rolando. The various parts of the internal 
capsule are represented by H, K, and L. H represents the internal 
capsule ; K, the " pyramidal " region of the posterior segments of the 
internal capsule, and L the part concerned in sensation. The anatomical 
arrangement of the internal capsule may be diagrammatically represented 
by the tract of white represented by the letters H and K in the above 
diagram. It will be noticed that these tracts unite at an obtuse angle, 
which latter by the Germans and French is known as the " knee of the 
internal capsule." The anterior segment of this collection of fibres contains 
those which are essentially motor, while the posterior are sensory. The 
knee contains fibres which terminate in the bulb and have a con- 
nection with some of the great nerves of the medulla concerned in this 
voluntary innervation of the tongue and other parts of the face. 

In the diagnosis of cerebral disease it is well that we should bear in 
mind the relation of cerebral ganglia and their commissural connections, 
and a transverse section of the brain, when studied microscopically and 
otherwise, will enable us to see that not only are the two hemispheres 
connected together, but the various gray segments are brought into rela- 
tion by different sets of fibres which may be briefly enumerated as 
follows : Fibres Avhich connect the optic thalamus and the lenticular nu- 
cleus and the caudate nucleus with the periphery of the brain ; fibres 
connecting the lenticular nucleus with the gray matter of the sphenoidal 
lobe. These internal intercommunicating fibres form a system by them- 
selves, while a second set of fibres having a direct course, (peduncular 
fibres) serve for the direct reception and transmission of sensorial impres- 
sions and motor impulses. 

After the fibres of the internal capsule reach a lower and more posterior 
level they unite in the peduncle, which, according to Brissaud and others, 
contains four sets of fibres, each having a well defined office and correspond- 
ing with the arrangement in the internal capsule. They are as follows : 
1. A posterior bundle, the ofiice of which is the conduction of sensory 
impressions. 2. A bundle composed of fibres especially engaged in the 
motor innervation of the trunk and limbs. 3. A small bundle of fibres 
connected with the angle (genou) of the internal capsule, and which con- 
tain motor fibres connected with the bulb ^ and are concerned in voluntary 
movements of the face, and tongue. 4. An internal bundle of fibres 
going to the bulb. 

Evidences of secondary degeneration, after certain cerebral lesions in- 

1 Loc. cit. 



CEREBRAL HEMORRHAGE. 109 

volving the motor track are best seen in the inner and middle thirds of 
the peduncle and sometimes occupy a pyramidal character the base being 
anteriorly. 

The course of the motor fibres has been studied most fully by Flechsig 
in the embryo, and he has materially overturned the old views — notably 
those of Brown-Sequard in regard to the total decussation of fibres in 
the pyramids. Flechsig has found that the extent of decussation is very 
variable, and that in the great number of cases there is by no means total 
decussation. This will explain the possibility of hemiplegia upon the 
same side as the cerebral lesion in individuals in whom the pyramidal 
decussation is imperfect. 

The study of sensory disturbances following brain lesions has not kept 
pace with that of the localization of motor troubles. Certain facts have 
been clearly brought forward, however, and the most important of these 
is that injury of the posterior segments of the internal capsule is produc- 
tive ofhemiausesthesia. Veyssiere^ was the first to make this clear, and 
Charcot, Ferrier and others have since proved the connection of such 
unilateral anaesthesia with loss of smell and vision upon the same side. 
Injury of the convolutions about the fissure of Rolando has not been so 
far found to be followed by general ansesthesia, although according to 
Ferrier the occipital convolutions seem to some extent to possess sensorial 
functions. The optic thalamus has undoubtedly much to do with sensory in- 
nervation, and Friedrich and Charcot have both found that hemorrhage 
or tumor in regions adjacent to the posterior part of this organ produced 
anaesthesia, and in certain cases of epilepsy, with peculiar sensory aurse. 
Hammond has regarded the optic thalamus as the seat of the lesion. 

The blood supply of the brain is derived from two systems of vessels, a 
basal or central, and a cortical or external. 

It has been proved by Duret and others that there is no distal connec- 
tion between these two, and that the central arteries as a rule supply but 
a limited territory. The importance of the central arteries, which are 
much larger than those supplying nutrition to the cortical gray matter, 
is derived from the fact that in rupture or disease much more profound 
and sudden symptoms occur than when the others are affected, because of 
the existence of anastomoses in the latter. Charcot alludes to several 
facts which in this connection should be borne in mind in the localiza- 
tion of symptoms. 1. Vascular lesions upon the surface of the brain 
and hemorrhages as a consequence do not occur so often as in the sub- 
stance of the brain, for the reason that the cortical vessels are protected 
in their course by their dura mater and other coverings, that they are 
smaller, and are not subjected to so much pressure as those of the cen- 
tral system. 

2. Proximity of the arteries of the central system to the heart — their 
simple arrangement and liability to sudden pressure predisposes to acci- 



^ Recherches Clinique et Experimeutales, snr rheiniansesthesie. Paris, 1874. 



110 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

dents in deeper parts, and for this reason central or deep hemorrhages are 
serious. 

A reference to Fig. 18 will enable the reader to appreciate the vessels 

Fig. 18. 



(Charcot.) 
Fig. 18., (Charcot). Central vascular supply. A. Territory of Sylvian artery. B. Ter- 
ritory of anterior cerebral arte^}^ C. Territory of posterior cerebral artery. D. External 
vrall. E E E E. Internal capsule. F. Walls of Trigonal arches. G. Lateral ventricle. H, Caudate 
nucleus. I. Island of Reil. J. External arteries of corpora striata. L. Sylvian artery. M. Internal 
carotid. N. Gray substance of third ventricle. O. Optic chiasm. P. Section of optic nerve. Q. 
Lenticular nucleus. R. External capsule. S. Anterior cei'ebral artery. Vascular areas are indi- 
cated by dotted lines. 

concerned in the supply of the central ganglia. The Sylvian or 
middle cerebral artery is the most important of these, and it will be 
found that when it leaves the internal carotid it sends up central 
branches to supply a part of the caudate nucleus, the entire lenticular 
nucleus, the internal capsule and a part of the optic thalamus. It will be 
seen by the dotted lines that nearly two-thirds of the hemisphere is sup- 
plied by this important vessel and its central and cortical branches. The 
posterior cerebral artery furnishes nourishment to the parts of the optic 
thalamus not supplied by the Sylvian — namely, the external and posterior 
parts. It also supplies the tubercula quadrigemina and the crura cerebri. 
The anterior cerebral artery is concerned only in the supply of a small 
part of the caudate nucleus. 

Fig. 19 shows the course of the middle cerebral artery which sends off 
branches to supply the cortical portions of the brain after it fulfils an 
equally important office in supplying, at the base, central vessels to the 
ganglia. 

The cortical branches of this vessel are quite large, and are four in 



CEREBRAL HEMORRHAGE, 



111 



number. These severally supply the frontal, parietal, and sphenoidal con- 
volutions The island of Reil is supplied by a large branch which leaves 
the main artery when it divides into the large terminal branches. The 
four vessels alluded to, break up into smaller or secondary arteries at 
higher points, such secondary arteries supplying a small track of convo- 
lution. There are still " tertiary bran chlets " which anastomose with 
each other forming arborescent ramifications — though Duret does not agree 
with Charcot and others regarding this fact. 

Fig. 19. 




L !V1 N 

(Charcot.) 

Cortical branches of Sylvian artery. ABC. Frontal Coxvolutions. D. Ascending Feontal 
Convolution. E. Ascending Parietal Convolution. H. Infra-parietal convolution. G. Supra- 
Parietal Lobule. L Occipital Lobe. J. Trunk of Sylvian Artery. K. Perforating branches of 
central gray ganglia. L. Ext. and superior frontal branches. M. Ascending frontal artery 
N. Ascending parietal artery. 0. Parieto-sphenoidal and sphenoidal arteries. 



Upon the surface of the convolutions we find nutrient arteries of small 
size and capillary character, which are branches of the " tertiary branch- 
lets." These arteries enter the cortex at a right angle with its external 
surface and are called long and sliort, with reference to their extent of 
penetration. The long or " medullary " arteries, are terminal vessels of 
the tertiary branchlets and pass perpendicularly into the gray cortex and 
white substance, hut have no connection luith the cerebral arteries below, 
while the short cortical or nutrient arteries, which also come from the 
tertiary branchlets or ramifications, rarely extend deeper than the corti- 
cal gray matter. The only diiference in the character of the two forms 
of nutrient arteries, for they have a common origin, is that they extend 
to different distances from the cortical periphery, and while one supplies 
chiefly one form of nervous matter, (the white) the other nourishes the 



112 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

gray. It will be found that a sort of arborization or net-work is found in 
the gray matter, which depends chiefly upon communicating arteries 
from the short vessels with an occasional reinforcement from the longy 
and also that the terminal branches of the large trunks are entirely 
distinct from those arising from a lower level, and which enter the 
brain at a basal point to become central arteries. 

Other cortical parts of the ^rain are supplied chiefly by branches of 
the anterior cerebral, and posterior cerebral arteries. 

The pathological course of cerebral hemorrhage is the following : 1 . The 
stage of preparation, during which the arteries undergo the changes already 
spoken of. 2. The operation of an exciting cause, the rupture of the ves- 
sel, the injury of the nervous substance, and the formation of the clot. 
3. Death ; absorption, or limitation. 

Bouchard^ and Charcot both affirm that cerebral hemorrhage is always 
dependent upon a peculiar kind of disease of the vessels. This diseased 
condition consists of a studding over with minute aneurismal dilatations 
which have been called by them " miliary aneurisms." These arise from 
a primary degeneration of the outer coat of the vessel, secondarily 
sclerosis, and finally atrophy, of the muscular coat and dilatation. Of 
sixty-five cases of cerebral hemorrhage, they found miliary aneurism in 
every instance. Both of these authors consider the vascular change to 
be different from that of atheroma, which begins in the inner coat. These 
appearances are confined to the brain, and exist where there is no evi- 
dence of atheroma to be found in any other part of the body. Notwith- 
standing the fact that these views are endorsed by such men as Meynert, 
Bastian, and others, there are many observers who consider miliary 
aneurisms to be due only to careless manipulation, or to be identical with 
the " hyaline degeneration" of Gull and Sutton which is found in other 
localities. 

Dr. Barlow- has presented a case which fully demonstrates that cere- 
bral embolism may produce a conditon of the vessels which leads to the 
formation of aneurisms, first causing local arteritis and weakening of the 
wall of the vessel. In this case (that of a boy aged ten years) there 
was right and afterwards left hemiplegia, and aortic regurgitation. The 
autopsy revealed '' cortical softening on each side of the lower part of 
the ascending frontal and the posterior parts of the second and third 
frontal convolutions. The clue to this condition was found in the middle 
cerebral arteries. On both sides these vessels were diseased at the spot 
where the fine branches were given off* over the island of Reil for the 
supply of the cortex. Of these branches on both sides, the one supplying 
Broca's convolution and the one supplying the ascending frontal were 
also diseased. There was no aneurism to be discovered anywhere, but 
the walls of these vessels presented many small calcified nodules obvious 
to touch and sight." This calcification was not noticed in any other 



Archives de Physiol., 1868. 

Brit. Med. Journal, April 7, 1877, p. 372. 



CEREBRAL HEMORRHAGE. 113 

vessel in the body, and emboli had lodged in the spleen and kidneys. 
In Goodhart's cases actual aneurism had followed the embolism, and 
Dr. Barlow's case demonstrates that there is a primary weakening. 

Durand-Fardel ^ found that of 32 cases the arteries were only healthy 
in 9 cases, while in 21 they were thickened, and in 2 ossij&ed. 

AndraP found that of 32 cases the arteries were apparently healthy 
in but 4. 

These miliary aneurisms have been said to be due to " periarteritis," but 
it cannot be denied that a large proportion of cases of renal and heart 
disease produce modifications in blood pressure, which would account for 
the rupture of the vessel without any primary inflammatory condition. 

Fig 20. 




Miliary Aneurisms. 

I have repeatedly seen miliary aneurisms, and must confess that they 
appeared to depend upon some organic change which extended over a 
considerable space of time. 

Zenker differs from Charcot and Bouchard, and considers the internal 
coat to be that which is fi.rst attacked. When miliary aneurism exists, it 
is generally in conjunction with either gout, cancer, tubercule, leucocythe- 
mia, or other conditions, when leucocytes may pass into the cerebral ves- 
sels in large number. In old drunkards and general paralytics this vascular 
change is not an uncommon one. In regard to atheroma there have been 
many cases brought forward where this appearance was so constant as to 
gain recognition as one of the chief factors of the cerebral hemorrhage. An 
atheromatous artery contains deposits of a firm, semi-fatty nature, between 
its inner and middle coats. At an advanced stage the deposit is more 
calcareous and hard, and the artery may be sometimes easily broken in 
two. Occasionally the deposit between the^coats, by distension considera- 

^ Traite clinique et pratique des Maladies des Vieillards, Paris, 1854, p. 228. 
2 Clinique Med., vol. v. 
8 



114 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

bly narrows the calibre of the vessel, and in this way forms occlusion at 
one point while at a weaker one hemorrhage takes place. The veins and 
capillaries are not so often involved as the arteries. In regard to the seat 
of cerebral hemorrhages, we find from a table prepared by Kosenthal.^ 

rimes. 
In the corpus striatum alone 32 

" nucleus lentiformis alone 20 

" both these ganglia combined 8 

" corpora striatum and optic thalamus 7 

'' cent, nucleus and other parts (centrum semiovale, occipital lobe, 

island of Reil, pons and cerebellum) 6 

" optic thalamus alone 20 

" " " and Corp. striat. of both sides (recent hemorrhages 

and old cicatrices.) 2 

" " thalamus and lent, nucleus of both sides 3 

" centrum semiovale 3 

'' parietal lobe 2 

Total 103 

It may be stated that large portions of both hemispheres are de- 
stroyed without serious symptoms ; but when we approach the base the 
danger is increased, and if the third frontal convolution be the seat, we 
find a very decided and serious result, which is aphasia. The majority 
of hemorrhages are in or about the optic thalami and the corpora striata, 
together or singly, and if they be extensive the ventricles will be filled. 
If the hemorrhage be great, pressure may be made on the opposite side, 
or the blood may find its way into other "localities. In the anterior 
lobes the effusion is generally circumscribed, but from this site it may 
find escape into the lateral ventricles. In the ganglia and important 
parts at the base, the hemorrhage is generally small, but is all the more 
serious because of the importance of the parts it destroys. This is 
the case in the corpora striata. In the pons and medulla any con- 
siderable extravasation is followed by death or serious trouble. The shape 
of the cavity is variable, but in the gray matter it is circumscribed, and 
in the white it is irregular and elongated. 

Parrot^ reports 34 cases of cerebral hemorrhage in new-born children. 
In these the clot was found at the inferior part of the brain ; sometimes 
on the right side, but more generally on both sides. 

Should the patient survive the apoplectic attack, and die subsequently 
of some other disease, the cerebral clot will probably prove to be well 
organized, hard, and separated from the brain-tissue in the vicinity by a 
sclerosed mass. The immediate changes are the following : At the end of 
a few days the serum is absorbed, leaving the solid portion as a gelatinous 
mass ; finally the clot contracts, becomes yellow, and assumes the appear- 

^ A clinical treatise on the diseases of the nervous system, translated by L. Putzel 
N. Y., 1879, p. 38. 

2 Arch, de Tocologie, 1875. 



CEREBKAL HEMOEEHAGE. 115 

auce I have alluded to. It is rare that an old clot is completely absorbed, 
but it is found encysted and firm, and, perhaps, has produced some soften- 
ing. It is not uncommon to find more than one clot in a patient who has 
had several hemorrhages. There may be a cyst filled with thickened 
blood, which is indicative of an effusion of recent occurrence, and there 
may be others of smaller size, in different stages of resolution. Small 
aneurismal dilatations are also found, while local patches of softening, or 
cysts filled with clear serum, are not rarely present at the same time. 
Much has been said about the relation of decubitus to brain lesions ; how- 
ever, there does not seem to be any special connection between disease of 
certain parts of the brain and the causation of bad sores, though Joffroy ^ 
has reported three cases in which acute decubitus was found with lesions 
of the occipital lobe and optic thalamus upon the opposite side. Broad- 
bent, Dusaussay, Leloir and others have, however, presented a number of 
cases in which other parts of the brain were affected. 

A common form of hemorrhage is meningeal. Goodhart ^ has written 
an exhaustive paper upon this subject, in which 49 cases are given, prov- 
ing most conclusively its connection with diseased kidney and hypertro- 
phied heart. Of these 49 cases, 30 were due to renal disease, and six had 
uncomplicated heart trouble. When the hemorrhage takes place above 
the arachnoid, we are assured by Mr. Prescott Hewitt ^ that the blood 
very rarely gravitates to the base ; but when the hemorrhage is sub-arach- 
noid, the blood may find its way below, thus making the condition a most 
serious one. After death a peri-cortical collection of blood will be found ; 
which is extensive over the base, and probably produces death by pres- 
sure upon the pons and medulla. (See Chronic-Pachymeningitis with 
Hjematoma.) 

Diagnosis. — Coincident with the occurrence of the hemorrhage, symp- 
toms will be presented which may enable us to localize with some degree 
of accuracy the position of the clot, its extent, and character, and the fol- 
lowing statements are based upon the observations of Bastian, Wilks, and 
others : A lesion in or about the corpus striatum will be followed by hemi- 
plegia of the opposite side. The temperature being higher in the para- 
lyzed limbs than in the others ; the eyeballs will deviate towards the side 
of the lesion ; and the tongue, when protruded, will point to the hemiplegic 
side. The face is paralyzed on the same side as the arm and leg. A le- 
sion in or about the optic thalamus will present the same phenomena, only 
that the temperature is higher in the paralyzed limb than in the preceding 
form. A lesion in one erus is followed by very much the same symptoms. 
If the under and inner part be affected, we find cross paralysis, the face 
being paralyzed on the side of the lesion, while the extremities are para- 
lyzed on the other side of the body. Hemiansesthesia is quite marked ; and 
the third and seventh nerves are paralyzed, so that ptosis and profound 

^ Archives de Medicine, Jan. 1876. 
2 Guy's Hosp. Eep., vol. xxi. p. 131. 
^Holmes's System of Surgery, 1870. 



116 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

facial paralysis result. A lesion in one lateral half of the pons is followed 
by hemiplegia of the opposite side, profound coma, deviation of the eyes 
away from the side of the lesion, facial paralysis on the side of the lesion, 
lowered temperature in the non-paralyzed limbs, paralysis of the muscles 
of deglutition, and anaesthesia or hyperesthesia of parts supplied by the 
fifth nerve. A lesion of the upper half of the lateral region of the pons will 
be expressed by pretty much all of the symptoms which follow the last 
mentioned lesion, except that the facial paralysis will be on the side op- 
posite the lesion, A feature of all forms of lesions in the pons is the very 
decided character of the facial paralysis ; and if there be extension of 
the lesion, there may be double facial paralysis, with hemiplegia of the 
body. A lesion in the posterior part of the pons, beside the symptoms just 
alluded to, will produce paralysis of the fifth, sixth, and seventh nerves on 
the side of the lesion ; or, according to Brown-Sequard, it may sometimes 
produce cross-paralysis. A lesion in the centre of the pons is followed by 
double pa,ralysis, deep coma, marked contraction of pupils (while in the 
other forms one pupil may be contracted on the side of the lesion), lower- 
ed temperature on both sides, with ultimate rise and but slight loss of 
sensation. Liouville^ reports a case of hemorrhage into the pons, in 
which sugar was found in the urine. This he considers to be an ever- 
present symptom of disease in the lower part of the pons, but never a 
feature of disease of the upper part. A hemorrhage in the medulla is 
followed by paralysis of the cranial nerves on both sides, bilateral para- 
lysis of the body, and, generally, rapid death. Extensive lesions may 
produce a combination of these phenomena, and diagnosis may sometimes 
be an extremely difficult matter. A patient under treatment with sy- 
philitic disease of the brain, presents a combination of symptoms which 
are extremely interesting in a diagnostic sense. 

Wm. McG., aged 58 years, when about 21 years of age, had a primary 
chancre upon the dorsum of the penis, followed some months afterwards 
by secondary symptoms. After a few years all traces of syphilitic trouble 
seemed to have disappeared, as he enjoyed extraordinary good health. 
He has led for the last twelve or fourteen years a very intemperate life, 
and has regularly " gone upon sprees." Twenty-six months ago, after an 
attack of facial neuralgia, which was evidently specific, he became hemi- 
plegic during one of his drinking bouts, but does not remember any of the 
circumstances immediately connected with the apoplexy. When he be- 
came sober he found that the left side was paralyzed, but the loss of 
power could not have been very great, for he was able to walk in a few 
days. About a year ago the right side of the face became anaesthetic, and 
he began to lose the sense of taste on the left side ; at the same time he 
found it difficult to arrange the food for mastication, and his power of 
articulation became embarrassed. 

Present Condition. — Eyes. Pupils of the same size, and not abnor- 
mal ; respond well to light ; no ptosis, nor disturbance of vision ; no retinal 
change. Face. — No impairment of buccal muscles, nor of superficial 
facial muscles, except slight contraction of those of right side when he 

^ Gazette des Hopitaux, Feb. 8, 1873. 



CEREBRAL HEMORRHAGE. ' 117 

opens his mouth. When this is done, the orifice is unsymmetrical. Anos- 
mia marked, taste impaired to slight degree. Warm substances produce 
an impression on sound side of tongue, but not on the other. Left side of 
the palate paralyzed, and lower than the other. Left side of tongue atro- 
phied, presenting the appearance depicted in Fig. 21 ; and when protruded 
the tip points to the right side, no apparent tactile loss of sensation as de- 
termined by the sesthesiometer. Saliva is secreted in large quantities, and 

Fig. 21. 




Multiple Lesion with Tongue Atrophy. 

constantly drips from the angles of the mouth when he talks. Sensation 
of right side of face impaired ; feels points only when separated 3 mm. on 
other side IJ ; some difficulty of speech, especially with the letter r, pro- 
nouncing " righteous " " eightshus ;" the left leg he drags slightly when 
he walks. Six months ago he slept upon his arm when drunk, and thereby 
added to his other troubles a decubitus paralysis ; slight loss of power in 
both arms. 

In this case there were evidently two lesions — one in the medulla, and 
the other on the right side of the brain — one hemorrhagic, the other of 
slow growth. 

We are to diagnose the symptoms of cerebral hemorrhage in its different 
stages from those of the following diseases : Actual attack from ursemia, 
drunkenness, opium poisoning, tumor, epilepsy, compression or concussion 
from injury, embolism, and thrombosis. There are certain general ap- 
pearances which symptomatize the urcemic condition, and can hardly be 
mistaken ; the skin is waxy and osdematous, the eyelids are puffed, and 



118 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

the legs and feet swollen ; but, as Bastian suggests, it does not always 
follow, when we find these appearances in an individual over thirty- 
years of age, that the coma is always purely of an ursemic character, and 
that there may not be a complicating hemorrhage. The urine, when 
drawn, is found to contain albumen, but this symptom by itself is in- 
sufficient to settle the question. Ursemic coma is generally of gradual 
appearance, though Hughlings Jackson calls attention to a form w^hich 
has a rapid onset, with convulsions ; but, on the whole, such sudden 
appearance is more suggestive of cerebral hemorrhage. It is nearly 
always preceded by prodromata for several days. The patient is stupid, 
and inclined to somnolence, and has headache. Bourneville has ascer- 
tained that the temperature rapidly sinks when the coma begins, to a 
])oiDt YQTj much lower than it does in cerebral hemorrhage, and con- 
tinues depressed during the condition, while the converse is true in the 
other affection. Convulsions are much more prominent and constant 
features of ursemic coma than they are of cerebral hemorrhage ; and, be- 
side, there is no paralysis. I^umerous other indications will serve to 
make the diagnosis clear in this respect. The coma is not deep, and it is 
possible to arouse the patient, and there is great hyperkinesis, there being 
a tendency to muscular spasm and rigidity which is not unilateral. The 
character of the respiration differs from that of cerebral hemorrhage, the 
stertor being more superficial. From drimhenness the diagnosis is not 
always so easily made, the two conditions sometimes coexisting, and it 
may be necessary to delay until the eflTect of the alcohol has passed away, 
before we can determine our patient's true condition. The odor of liquor, 
the circumstances under which he was found, and his imperfect loss of 
consciousness, are sufficient to excite suspicion. If he vomits, we may 
chemically test the substances thrown up, or examine the urine. 
Anstie gives a delicate test which may be employed. If even only one 
drop of the urine of the patient who has taken a toxic dose of alcohol be 
added to fifteen minims of a solution of one part of bichromate of potash 
in three hundred parts of strong sulphuric acid, the mixture will turn 
to an emerald green. With a larger quantity this test will be much more 
certain. The articulation of an intoxicated person when aroused is so 
peculiar and so interrupted by hiccough that there need be no chance for 
mistake in this respect. iVarcottc^oiso/imp' may resemble somewhat the 
symptoms indicating cerebral hemorrhage. Like alcoholic coma, its 
advent is gradual, and there are convulsions, while the face is dusky, 
but the patient may be generally aroused. Much stress has been laid 
upon the condition of the pupil in opium poisoning as a diagnostic sign ; 
but, as this symptom is indicative of hemorrhage in the ponS; it loses 
some of its value. Epileptic coma can hardly be mistaken (should it be 
a stage of the actual epileptic attack) for that of cerebral hemorrhage. 
la the former there is a history of convulsions ; the stupor lasts but for 
an hour or two at the most ; the temperature is elevated ; and there is 
sometimes an escape of bloody froth from the mouth. The previous 
history of the patient should set all other doubts at rest. Compression or 



CEKEBRAL HEMORRHAGE. 119 

concussion from head iDJuries may be mistaken for the condition under 
consideration. In the former there may be a subarachnoid effusion, 
which may give rise to many of the symptoms. The latter is usually 
of short duration, so far as symptoms are concerned. The skin is pale, 
the pupils dilated, and vomiting occurs at some time or other. It is al- 
ways of decided importance that we should inquire into the nature and 
receipt of the injury ; for, should it follow a fall while the patient is in a 
safe position, we miy suspect that he has had a seizure of some kind, 
the injury being secondfiry to the attack. 

The inteimal cause of the hemorrhage is always important, whether it 
be produced by an abscess, tumor, or other intracranial disease states ; 
and these things are to be taken into account. The antecedent history 
of the patient, the presence of pain of a localized character, subsequent 
convulsion, loss of vision, aural disease, and kindred conditions should 
all be ascertained. Serous apoplexy, as it has been called, when an 
immense effusion of serum takes place either beneath the investing 
membrane, or in the ventricles, or throughout the brain substance, 
is usually of gradual origin, and dependent upon the collection of 
fluid . which takes the place of atrophied brain substance or attenuated 
vessels. 

Prognosis. — According to all observers it is an exceedingly difficalt 
matter to make a prognosis with any certainty, especially an early one, 
and, consequently, it is of the utmost importance that every circum- 
stance of the case should be taken into account and carefully considered 
before we give expression to any opinion. Certainty of prediction is 
made doubtful, by new complications, and fresh dangers that are likely 
to arise. There are several questions that are to be answered, and the 
first of these concerns the fatality of the actual attack. The character 
of the coma, its depth and duration, the appearance of convulsions, aboli- 
tion of reflex excitability, stertor, involuntary passage of urine and feces 
are to be regarded as indicative of an early fatal termination. If this 
condition be connected with unequal pupils, and double hemiplegia, the 
prognosis is, if anything, more unfavorable. Large hemorrhages into 
the ventricles, corpora striata, or into the crura or pons' are then to be 
feared. The patient presenting these alarming symptoms dies usually 
in a very short time, say in from a few hours to two or three days, and 
there may be, perhaps, an aggravation of the symptoms towards the end 
as the result of fresh hemorrhage. If he survives the attack, what are 
the chances for the return of mental power ? or, if not affected, will it 
subsequently become impaired ? This depends very much upon the 
occurrence of inflammatory action about the clot, or whether there be 
ursemic trouble or softening. TVe may augur well for his chances if 
these conditions are absent, and if he lives for eight or ten days after 
the immediate attack. In regard to the speech disturbances : if there be 
simple ataxia, there is no reason to fear ; if, however, any marked for- 
getfulness of words or genuine aphasia exists, the prognosis is less hope- 
ful. This condition of affairs often exists for years without the slightest 



120 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

improvement taking place. At first the mind ia confused and dull, and, 
unless the hemorrhage is the result of softening or other degeneration, 
there is but little doubt that he will ultimately regain his mental activity. 
It is, however, well to qualify this statement by saying that in old people 
the tendency is the other way. Congenital apoplexies, or those occurring 
in early life, are apt to leave sequelae of the most deplorable description, 
such as imbecility and kindred conditions. The return of muscular power 
and normal sensation is the most important question to be next con- 
sidered, for much of the patient's future comfort depends upon the re- 
covery of his lost power. Should the limbs remain paralyzed, or second- 
ary neuritis take place, the consequence will be atrophy and contractures, 
such as I have described. It is, however, usual for recovery to begin in 
a few weeks, and in even a shorter time should the hemorrhage be unat- 
tended by loss of consciousness. The limb first to recover is the lower 
extremity. He is able after a short time to get out of bed and " hobble " 
about, or he may retain a certain degree of power from the first should 
the hemorrhage be slight. He is subsequently able to raise his hand to 
his head, and ultimately recovers entirely. But this improvement does 
not always occur, for duriug cerebritis, and secondary degeneration 
which may subsequently take place, a number of serious muscular dis- 
tortions of a permanent character may ensue. A case illustrating this is 
the following : — 

J. C. D., aged 53, born in Ireland ; carman. Family history, mother 
died of old age ; father died of renal disease. The patient in early life 
was very intemperate, and there are some evidences of syphilitic trouble, 
there being nodes, bald spots, and enlarged glands ; but he denies any 
venereal disease. For three months previous to the attack (it occurred 
three years ago) he sufiered from headache, dizziness, and other prodro- 
mal symptoms ; none very marked, however. He went to bed one night 
feeling perfectly well, and awoke with " cramps," which affected his right 
leg ; he called his wife, and attempted to get out of bed, when he found 
he was paralyzed. There was no speech trouble whatever. He was placed 
iu bed, and remained there for three months, during which time he had 
violent headache in the occipital region. 

Present Condition. — Hemiplegia of right side, sensibility slightly im- 
paired, and no atrophy of either the arm or leg. When he stands there 
is slight rigidity of the inner ham-strings. The toes and the end of the 
foot are adducted ; and when he walks, the foot is raised from the ground 
about one inch ; the knee is rigid, and there is motion only at the hip- 
joint. The fingers of the right hand are in a condition of extreme 
flexion, and cannot be extended by ordinary force ; but, when the hand 
is placed in hot water for some time, the rigidity is partially overcome. 
The thumb is not involved ; but, when the distal phalanx was extended, 
it could be bent backwards some distance, and remained in this condition 
until it was restored by me. The hand is slightly flexed, and the fore- 
arm pronated and flexed on the arm, and the arm adducted to the body. 
No lateral movement is possible. There was an early history of neuritis, 
which came on a short time after the attack, with decided pain in the 
shoulder-joint, during which the patient applied blisters and mustard 
poultices. The dynamometer indicates 20, outer circle, with the right 
hand, and 80 with the left. There is no visible facial paralysis, but the 



CEREBRAL HEMORRHAGE. 121 

tongue points slightly to the right side. The surface of the paralyzed 
side is mottled and cold, and the nails are crenated and horny. 

The facial paralysis is sometimes a grave and permanent condition, 
and is very serious, especially if there be ptosis. Should the paralysis 
involve the muscles of the pharynx, the tongue, or the buccal muscles, 
the prognosis is very bad, and these symptoms suggest that the hemor- 
rhage has invaded the posterior basal parts of the brain, and perhaps 
the medulla. The organs of special sense are affected to a variable ex- 
tent, and greatly modify the prognosis. If there be involvement of the 
optic-discs, retinal extravasations, or structural changes of the fundus, a 
grave character is given to the disease ; while such symptoms as ptosis 
and diplopia, which depend upon paralysis of the third and sixth nerve, 
sometimes disappear after a time, though such disappearance may very 
slowly take place. The recurrence of apoplectic attacks is not uncom- 
mon, and if there be any special cachexia, they are to be dreaded. Sy- 
philis and gout, as well as renal disease, are highly conducive to a return 
of the trouble ; or advanced age is an important predisposing cause of 
cerebral hemorrhage. When we find a calcareous state of the arteries 
with cerebral hemorrhage, it is very probable that the other fluxions will 
follow. I remember a case in which a succession of hemorrhages oc- 
curred in the person of a middle-aged lady, the third of which proved 
fatal: — 

N. G. A., aged 57. On the evening of February 3, 1873, I was called 
by Dr. Wm. H. Bennett to see the patient, whom I found in a state of 
coma. All of the characteristic appearances of a profuse cerebral effu- 
sion were manifested. The apoplectic seizure had taken place the day 
before, and she had continued in a comatose state until I saw her with 
Dr. Bennett. Her surface was cool, her breathing slow and stertorous, 
her pupils dilated, and cornea insensitive to the touch ; while reflex ex- 
citability was entirely abolished, so that tickling of the soles was followed 
by no withdrawal of either limb. In this state she remained until the 
8th of the month, during which time, and in fact until the time of her 
death, in November of the same year, it was necessary to draw her water 
nearly every day. At the end of the fifth day there was a slight return 
of consciousness, but entire inability to speak, the patient making a pecu- 
liar short sound when she wished to communicate with those about her. 
There was complete paralysis of the right side, but a faradic current 
readily produced muscular contractions. From this period until Septem- 
ber 13th, there was steady improvement, and the family, as well as our- 
selves, were very hopeful. She recovered considerable power over the leg 
and arm, but was unable to get out of bed, although she was lifted from 
it and placed in an easy chair, where she remained contented for several 
hours of the day. She was now able to utter two or three words, and 
seemed to take a lively interest in all that went on about her. On the 
13th of September, while lying in bed, she suddenly became comatose, 
and presented all the symptoms of a fresh hemorrhage. Her tempera- 
ture, which had before ranged between 98° and 101°, now sank to 96° ; 
and her condition was so critical that I remained with her during the 
night of the 14th, when she slightly recovered, regaining her conscious- 
ness on the 17th ; but there was complete loss of power. The tempera- 
ture now rose to 104°, and she was restless and irritable. Her power 



122 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

of expression bad entirely disappeared, and she remained in this state 
until the 19th of November, when she died in her last apoplectic attack. 

This patient, before her last illness, had suiFered for some time from 
albuminuria, but her symptoms had been almost entirely relieved when 
her first cerebral hemorrhage took place. She was of spare build, her 
radial arteries were rigid, and the arcus senilis was visible to a limited 
extent. 

This tendency to cerebral hemorrhage is sometimes seen in gouty sub- 
jects. A patient recently sent to me by Dr. William Lockwood, of Nor- 
walk. Conn., had suffered for years from gouty trouble. Besides the pain, 
her joints presented gouty swellings, with chalky concretions. Within 
the past five years she has sufiered from slight hemiplegia of both sides ; 
on the right most severely. In this case it is probable that the rupture 
of a large vessel will some day carry her off. 

Treatment. — Our treatment must be, first, preventive, second, for 
the attack, and third, for the amelioration of the resulting condition. If 
we have to deal with cachexias of different kinds, appropriate treatment 
is indicated. Should there be gouty trouble, albuminuria, or syphilis, 
these are to be met with alkalies, diuretics, and specific remedies, such as 
mercury and the iodides. If there be depraved general health, weak 
heart action, and general debility, we are to support our patient by qui- 
nine, stimulants, and nourishing food. Combinations of digitalis and iron 
are especially useful when there is low arterial tension, and rapid heart 
action. In speaking of cerebral congestion I alluded to the conditions 
which might favor an excessive flow of blood to the head, and advocated 
special forms of treatment. It is not necessary to repeat these indications, 
but I will simply refer to the value of the bromides given in doses of from 
20 to 30 grains three times a day if there be any tendency to head fulness, 
while ergot administered in half-drachm doses two or three times during 
the 24 hours, and the abstraction of blood from behind the ears, may be 
resorted to, should there be a suspicion of immediate danger. The patient 
is to be kept perfectly quiet in a cool room, cold applications are to be 
made to the head, and his bowels should be emptied by some such cath- 
artics as the compound jalap powder, senna, or Eochelle salts. Should 
we recognize the appearance of any prodromal symptoms, we must im- 
mediately inform the patient of the dangerous possibility, and enjoin upon 
him the necessity of regulating his mode of life, of breaking off bad 
habits, and using every means in his power to improve cutaneous circula- 
tion. The flesh-brush, cold, and sometimes Turkish baths, moderate out- 
door exercise, and other agents which stimulate the surface capillaries and 
relieve internal congestion, should be as soon as possible resorted to. The 
patient's diet should be farinaceous, and the use of either strong drink or 
condiments is to be at once discontinued. He is to sleep in a cool room, 
and on no account wear tight neck gear. The feet are to be kept warm, 
and thick woollen stockings should be recommended. Violent exertion, 
especially forms requiring any fixation of the abdominal muscles or 



CEREBRAL HEMORRHAGE. 123 

straining, are also to be carefully guarded against. Should we be called 
to find the patient in the actual apoplectic state, another line of treatment 
must be followed out. If in this condition he is found lying in a coma- 
tose state upon the floor, he is to be lifted gently, carried to a bed, and 
well propped up by pillows, so that the head is elevated. The room 
should be kept cool and well ventilated, and cold applications are to be 
applied to his head, while his feet may be kept warm by contact with 
bottles filled with hot water. The room is to be darkened, and his collar 
and shirt collar band should be cut or ripped oiF, so that' the flow of blood 
to and from the head shall be unembarrassed. It is essential to keep him 
perfectly quiet ; so loud talking is to be forbidden, and officious friends 
kept away. In times gone by, it was customary always to bleed at this 
stage. I think experience has clearly proven how dangerous is such prac- 
tice, for hemorrhage in the brain is very apt to be started afresh by any 
such measure. If, however, the pulse be full, strong, and bounding, the 
patient's face flushed, and his condition one of plethora, the abstraction 
of a few ounces of blood from behind the ears, with cold douches to the 
head and inustard plasters to the calves, will do much good. This condi- 
tion may be so patent to the observer that, perhaps, in rare instances, and 
after careful deliberation, he may decide to abstract ten or twelve ounces 
from the arm. If we hear that he has been constipated for several days, 
a drop or two of croton oil or half a grain of elaterium may be given in 
a wafer, or applied to the tongue if he is unable to swallow ; it is advi- 
sable to give the first remedy, however, if the patient is profoundly coma- 
tose. Should there be much cardiac excitement, no better medicines can 
be recommended than tincture of veratrum viride, or tincture of aconite ; 
the former in doses of from 6 to 8 minims till the pulse force is decreased, 
and the latter in rather large doses, say from 4 to 6 minims at a time, and 
after an interval of four hours, another dose, if the pulse has not decreased 
in volume or frequency. The medical attendant should not forget to draw 
the patient's urine frequently. I have known a neglect of this precaution 
to be followed by pain and distress which the patient in his helplessness 
is unable to express ; and I cannot impress too strongly upon the student 
the necessity of remembering this simple procedure. When consciousness 
returns we may continue the aconite if it is indicated, and perhaps com- 
bine it with small doses (say 10 grains) of the bromide of sodium every 
two hours. Active medication of any kind, however, is injudicious in the 
extreme ; so it will not do to give large doses. Should there be a condi- 
tion of prostration, a tablespoonful or two of milk punch may be given 
every few hours. The subsequent management of the case is sufficiently 
simple ; continued quiet, a moderate quantity of food easy of digestion, 
and attention to the functions of the body are the three indications. He 
should not be allowed to get up to defecate, but the bed-pan may be placed 
beneath him. It may be found necessary to give an enema, which is bet- 
ter than the administration of purgatives by the mouth, and in this case 
the patient should not be allowed out of bed, even though he may seem 
bright and sufficiently strong. Cleanliness should be insisted upon, and 



124 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

generally necessitates the faithful care of a responsible nurse ; for, if the 
patient is not carefully washed, the irritation produced by alkaline urine 
and his loose evacuations may favor the development of bedsores. As a 
precautionary measure, the buttocks should be rubbed with salt and whis- 
key, or, what is still better, tannin and alcohol. Bedsores may occasion- 
ally form, and sometimes are unnoticed by the physician if he is not on 
the alert, until his nose or the nurse remind him of their existence, the 
patient either being unconscious of such trouble, or unable to inform the 
physician even if he is aware of their presence. The patient should be 
immediately put on a water bed, and the slough removed by poultices of 
flax-seed and charcoal which may be sprinkled with iodoform. At the 
end of the 8th or 9th day, should the tendency be to recover}'', and the tem- 
perature normal, we are left with an ordinary case of hemiplegia. What 
is to be done next ? If the attack has been a serious one and signalized 
by marked loss of consciousness, and if the secondary rise of temperature 
be high, it is not best to begin electrical treatment for fully a month or 
longer. If the muscles respond too quickly to electric stimulus, we are 
not to use this agent, but to wait for some days or weeks, when we may 
cautiously employ the faradic current to the muscles of the affected side. 
Large sponge-covered electrodes moistened in a salty solution should be 
employed, so tKat all the muscles may be subjected to the electric stimu- 
lus in turn. Electrization may be direct or indirect, the muscles being 
made to contract either when both sponges are applied to their bellies, or 
when one is placed in contact with the muscle and the other is applied 
over the motor nerve by which it is supplied. In certain cases faradiza- 
tion fails to do any good whatever, and this is especially the case when 
there is delay in the absorption of the clot or any cerebritis. Two cases 
illustrating the possible advantages of this form of treatment are the fol- 
lowing : — 

Right Hemiplegia. — O. 8., aged 52, butler, came under my 
chptrge October 2d, 1872. He had been deprived of consciousness and 
power of motion a year before by a cerebral hemorrhage, and, after re- 
suming the duties of his avocation some months afterwards, continued 
well till three months ago, when a second attack prostrated him ; but, 
tiirough the good treatment he received at Bellevue Hospital, he partially 
recovered the power of locomotion. When he came to me for treatment 
there was complete hemiplegia of the left side. There was no peculiarity 
in his gait, beyond a very slight dragging. The arm was slightly atro- 
phied, and the amount of power exerted by a forcible grasp of the dyna- 
mometer was indicated by 15° of the lesser circle. He could not button 
his clothes, nor lift his arm above his head. There was no difficulty in 
speech, except it might be embarrassment in speaking the words contain- 
ing the letters " b " and " p," when the labial muscles were required. 

Electric irritability in the arm was slightly exaggerated. After giving 
him a simple prescription for his constipation, I dismissed him. 

In three weeks afterward he returned in very much the same condi- 
tion. I then systematically applied the galvanic current to the head, 
and the faradic to the limbs. The improvement was marked and imme- 



CEREBRAL HEMORRHAGE. 125 

diate. The muscles lost their atrophic state, and became firmer and 
larger. The patient was able to perform many actions with his hands 
not possible before this treatment. Faradization to the lips and cheek 
has effectually overcome the facial paralysis, and he now speaks dis- 
tinctly. 

Cerebral Softening ; Right Hemiplegia. — H. AValker, aged 62, Germany, 
canal-boat captain, presented himself for treatment in December with a 
well-marked right hemiplegia. He had been injured some time before 
while on the deck of his canal -boat, and then hit upon the head. He 
was senseless for some days, but recovered, with severe cerebral disturb- 
ance, which, from his wife's statement, must have been inflammation of 
the cerebral substance. 

He left his bed after some weeks, with persistent pain in the head, 
aphasia, trembling, and a heavy feeling of the lower limbs. His 
memory and other mental faculties became obscured, and there was an 
uneasy expression of the eyes. About a year after the receipt of his 
original injury, while working one day in the sun, he had an apo- 
plectic fit. 

After remaining in bed some time, muscular power and cutaneous sen- 
sibility slowly came back. He was able to walk with difficulty ; his speech 
was indistinct; the muscles of both the leg and arm were greatly atro- 
phied ; and I determined to use faradism. 

The constant use of the veiy mild current for several weeks brought 
back, to some degree, the original contour of the paralyzed muscles. He 
was able to progress with a cane, but his speech remained imperfect. 
During the treatment he had repeated premonitory signs of a new attack. 
Faradism was resorted to to prevent atrophy,- but its good effects were 
only temporary, as there is still softening. 

In connection with this treatment we may give at the same time either 
iodide of potassium, strychnine, or ergot. 

Iodide of Potassium. — Should there be a syphilitic history, I think we 
may begin at once with this remedy. If there be no such dyscrasia, I do 
not approve of the remedy at any time. It is administered very often 
with the idea of producing absorption of the clot, and is recommended by 
many writers. IMy limited experience has convinced me that its virtues 
have been very much overestimated. I have found that in many cases 
the patient's tendency to recovery was hastened more by rest, good food, 
and fresh air, than by any other form of medication. It is perhaps of 
value in old cases. 

Phosphorus. — Either in its pure state, or in combination with zinc, it 
is of great benefit in cases of long standing, especially if there be debility 
and tardy restoration of power in the paralyzed limb. The phosphide of 
zinc in doses of one-third of a grain, or dilute phosphoric acid in half-tea- 
spoonful doses, are perhaps better borne than pure phosphorus. 

Strychnine is entitled to more consideration. If used at the proper 
time, it is more powerful to do good than any other remedy I know of, 
perhaps excepting electricity. "When the exaggerated electro-muscular 
irritability subsides, we may give it in doses of 1-32 of a grain three times 
a day, but before this time its use is attended with danger. 



126 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

Vance ^ has recommended hypodermic injection of strychnine, but I 
always hesitate when injecting an irritating substance into the belly of a 
paralyzed muscle, for I have repeatedly seen abscesses follow the use of 
even a neutral solution properly injected. Impaired muscular vitality and 
tardy reparative nutrition do not favor its use. However, Bartholow, 
Eulenberg, and Echeverria recommend its employment, and have had 
good results. Perhaps in paralysis of central origin the trouble to which 
I have alluded is not so much to be feared as when the affection is 
peripheral. Each muscle is to be subjected to injection, one being so 
treated each da}^ Instead of the plan recommended by these authorities, 
viz., injections into the substance of the muscle, I prefer local subcutaneous 
introduction of the solution by the hypodermic syringe. In additi/on to 
electric treatment, it is well to resort to massage and passive movement of 
the contracted members. The patient may be directed to do this himself, 
and he should be told to rub the paralyzed limb several times daily for at 
least fifteen minutes at a time. Dr. G. M. Beard has recommended heat 
in the treatment of paralysis, and his plan is to place the affected limb in 
a heated earthen drain pipe, well lined with flannel. I can quite agree 
with him, but have found that alternate heat and cold applied to the sur- 
face produce more rapid improvement in nutrition of parts which have lost 
their power. I originally recommended the instrument depicted in Fig. 22, 
which will be found a cleanly and convenient apparatus. One receptacle 
is filled with hot water, the other with cold. If the contracted limbs 

Fig. 22. 





Instrument for applying Heat and Cold. 

where lately rigidity has taken place are allowed to remain daily for 
fifteen minutes or half an hour in quite hot water, much benefit will 
follow; or, should there be neuritis, we may use blisters, or the actual 
cautery along the course of the nerve trunk. It is of the utmost import- 
ance that everything should be done to improve the patient's hygienic 
surroundings, diet, and habits. He should not remain in-doors, but stay 
in the open air as much as possible. Food of a nutritious but not of a 
fatty character, moderate stimulation if needed, and a course of tonics, 
may constitute our form of treatment during this late stage of the dis- 
ease. 

1 Journal of Psychological Medicine, April, 1870. 



1 



CEREBRAL ANiEMIA. 127 



CHAPTER III. 

DISEASES OF THE CEREBRUM AND CEREBELLUM (Continued.) 
SYMPTOMATIC CEREBRAL ANiEMIA. 

Synonyms. — Syncope, Anemie Cerebrale, Hydrocephaloid. 

Definition. — A morbid state characterized by an insufficient cere- 
bral blood-supply, and expressed by impairment of consciousness, pallor, 
and much muscular enfeeblement. This disease is capable of quite as great 
modification as cerebral hyperaemia, as it may be what only appears to be 
a continued physiological condition, or a grave pathological state. Cere- 
bral anaemia may occur : 1, in an acute form (syncope) ; 2, in a chronic 
form ; 3, in an infantile form (the hydrocephaloid of Marshall Hall) ; 
and, 4, it is localized or partial, as a result of vascular obstruction. The 
acute form, which may be only a simple fainting attack, or the result of 
shock following severe hemorrhage, is the most familiar variety. It is 
hardly necessary to describe the alarming and familiar condition that we 
occasionally meet with after post-partum hemorrhage, or protracted decu- 
bitus, when the patient assumes the erect posture. The chronic variety is 
much less serious in its earlier stages, though, when continued, it is often 
the forerunner of certain forms of insanity. It is symptomatized by 
lowered function of the cerebral ganglia, depraved nervous tone, and 
general intellectual apathy; for, as normal circulation is necessary for the 
support of healthy brain action, and as we find that rapidity of thought 
and emotional activity are proportionate to the increase in the cerebral 
blood-supply, so must insuflScient circulation bring with it an impaired 
state of intellectual functional activity. This loss of healthy action may 
be expressed by drowsiness, obscured intelligence, or by irritability and 
restlessness. 

The infantile form generally follows some of the continued fevers of 
early life, and is a disease of childhood. Occurring during the stage of 
convalescence of the acute form, it is symptomatized by semi consciousness, 
diarrhoea, great exhaustion, insensitive pupils, pallor, sighing respiration, 
and other symptoms. 

The last variety, local or partial cerebral anaemia, is that which is usu- 
ally productive of right hemiplegia, and is due, in the majority of cases, 
to thrombosis or embolism, and often has a grave termination. 

It is hardly necessary to allude to acute cerebral anaemia, for it comes 
within the province of the surgeon rather than within that of the neuro- 
logist. Following some grave accident when there is sudden and excessive 
loss of blood, we shall find a corresponding loss of consciousness, and 
muscular power, sighing, and slow respiration, generally vomiting, and 
involuntary discharge of feces and urine. 



128 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

The condition is not a lasting one, and provided the hemorrhage has 
not been too excessive, nor the shock too great, there may be a retrograde 
disappearance of the symptoms, and ultimate recovery. 

Symptoms. — A. Chronic Cerebral ANiEMiA.* — Pallor of the 
skin, particularly of the face, which is of a dirty white color, while 
the sclerotics are milky blue, and the pupils widely dilated. The 
patient's expression is one of anxiety and depression, and if the condition 
be advanced and of long standing, he will spend hours with downcast 
eyes and a painful hopelessness, and hebetude stamped upon every feature. 
Coldness of the hands, heart-murmurs, and a weak, small pulse, are strong 
evidences of defective circulation of this description. The sphygmograph 
gives an almost straight tracing, the pulse-beats being weak and small. 
If the condition has gone on to the state where mental impairment has 
begun, we will generally find that there is venous stasis, and that the 
back of the hands is of a livid color, while pressure leaves a white mark 
which slowly disappears. The lips are pale, thick, and puffed, and the 
line between the mucous membrane and skin is less sharply defined than 
in the normal state. The urine is passed in large quantities, is colorless 
and limpid, and of a low specific gravity. The heart-sounds are weak, 
and it is not uncommon to find an aortic bellows murmur. Our patient 
complains of muscular debility, backache, loss of appetite, and somnolence, 
with great despondency, increasing loss of memory, marked headache, a 
regularly distributed cutaneous anaesthesia, sometimes nausea, hallucina- 
tions of sight and hearing, palpitation, indigestion, and constipation. I 
have been told very often by these patients that it was with very great 
difficulty that they could refrain from falling asleep in public places, and 
one lady was in the habit of becoming so drowsy in the street car on her 
way to my ofiice that she very often unconsciously passed the street. Wo- 
men who suffer in this way are subject to fainting attacks, which occur 
most often during the menstrual period. Among the most aggravating 
symptoms are hallucinations of hearing ; noises — such as ringing of bells 
— are heard ; and they occasionally have visual hallucinations in connec- 
tion therewith. Delusions are very unusual. Insomnia is sometimes a 
distressing symptom, though during the day, as I have before said, the 
patient may have great difficulty in keeping awake. It is not uncommon 
for him to complain of a sensation as of falling through the bed ; and 
one of the prominent elements of his sleeplessness is the continuous roar- 
ing in his ears, which is sometimes compared to the sounds heard when a 
shell or other hollow body is placed over the ear. There may be amauro- 
sis, and other defects of vision. Digestive derangements are quite common, 
and vomiting, which is cerebral, is in some cases frequent and obstinate. 
The individuals presenting these symptoms are poorly nourished. There 
may be oedema of the legs and ankles, and sometimes albuminuria. 

* This term is used with caution, as it will not do to be too positive in making 
a diagnosis unless we are sure of the existence of some general cause. There are un- 
doubtedly many cases of chronic cerebral ansemia due to the existence of organic 
cerebral disease which present symptoma mistaken very often for those of functional 
disease. 



CEREBRAL ANJEMIA. 129 

Feebleness and want of muscular power, of a light grade, are often ex- 
pressed ; and the comfort of a sofa or easy chair is sought by the patient, 
who seems disinclined to take any exertion whatever. 

B. Infantile Cerebral Anaemia. — Marshall Hall has called atten- 
tion to a most interesting form of ansemia, to which I have casually refer- 
red, and to which he has given the name " Hydrocephaloid." The 
disease depends principally upon exudation, and has its origin in early 
infancy. A case is related by Hall : — 

'* The patient, a boy, aged four, became comatose and perfectly blind 
and deaf. The finger might approach the half-closed eye without induc- 
ing any movement, but the moment it touched the eyelash, the eyelids 
would close. A spoon applied to the lips excited their action, and the 
food it contained was carried into the pharynx and swallowed ; the respi- 
ration was frequently suspended ; a sigh, and frequent respiration fol- 
lowed. The cerebral functions had ceased ; the true spinal functions were 
made."^ 

Marshall Hall lays down certain rules from which I may extract the 
following. We should especially be upon our guard not to mistake the 
stupor or coma into which the state of irritability is apt to subside, for 
natural sleep, and for an indication of returning health. " The pallor and 
coldness of the cheeks, the half-closed eyelid, and the irregular breathing, 
will sufficiently distinguish the two cases." He divides the affection into 
two stages, the first of which is one of irritability, the second, of coma. In 
the former there is some attempt at reaction, and in both stages there is 
some resemblance to acute hydrocephalus. 

" In the first stage the infant becomes irritable, restless, and feverish ; 
the face is flushed, the surface hot, and the pulse frequent ; there is an 
undue sensitiveness of the nerves of feeling, and the little patient starts 
on being touched, or from any sudden noise ; there is sighing, and moan- 
ing during sleep, and screaming ; the bowels are flatulent and loose, and 
the evacuations are mucous and disordered. If through an erroneous no- 
tion of this affection nourishment and cordials be not given, or if the 
diarrhoea continue either spontaneously or from the administration of 
medicine, the exhaustion which ensues is very apt to lead to a very differ- 
ent train of symptoms. The countenance becomes pale, the cheeks cool 
or cold ; the eyelids are half closed, the eyes are unfixed and unattracted 
by any object placed before them ; the pupils are unmoved on the ap- 
proach of light ; the breathing, from being quick, becomes irregular, and 
affected by sighs ; the voice becomes husky, and there is sometimes a 
husky teazing cough ; and evidently, if the strength of the little patient 
continues to decline, there is crepitus or rattling in the breathing ; the 
evacuations are usually green ; the feet are apt to be cold." 

It is my opinion that this form of disease is very much more common 
than it is supposed to be, and that many deaths usually reported as ma- 
rasmus are evidently of this nature. 

1 Op. cit., p. 181. 



130 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

Of local cerebral ancemia I will speak in another chapter. 

Causes. — As causes of cerebral anseiaiia we may roughly class all 
agents that interfere with the cerebral blood-supply, and consider them as 
remote or local. Whether the fault lies in a diseased heart, which is un- 
able to supply the brain with its normal amount of blood, or whether 
there is some mechanical obstruction through pressure upon the cerebral 
arteries, the morbid condition is the same. By far the most common cause 
of this cerebral condition is a general anaemia which may be dependent 
upon a number of conditions which drain the vessels. Among these may 
be enumerated uterine hemorrhages of various kinds, hemorrhoidal fluxes, 
cancers and other diseases attended by hemorrhage, as well as general dis- 
eases of assimilation which prevent the proper enrichment of the blood. 
A very slight reduction in the quantity of the blood will be followed 
usually by indications of the want felt by regions deprived of their nourish- 
ment ; but when the nervous system suffers this deprivation, the loss is 
immediately shown. Haller has calculated that one-fifth of all the blood 
in the body is sent to the brain, and with this fact in view, it will not be 
difficult to realize how any modification of circulation will result in im- 
mediate changes. Heart disease generally in the form of fatty enlarge- 
ment when there is mitral stenosis, or when functional activity is inter- 
fered with by emotional or other causes, may have much to do with 
cerebral anaemia. This cause enters, perhaps, more extensively into the 
production of chronic cerebral anaemia than any other. Owing to the 
delicate arrangement of the vaso-motor nerves which so beautifully con- 
trol the supply of cerebral blood, when through emotional or other causes 
the function is altered, there will be immediate intra as well as extra- 
cranial anaemia. We have all seen that sudden emotions not only blanch 
the face, but as well produce faintness. Various changes in the functions 
of the liver may be associated with states of cerebral anaemia through 
modification of function of this system of nerves. Milner Fothergill has 
pointed out the association between the nerves of this organ and those 
which supply the vertebral arteries ; and Schroeder Van der Kolk and Lay- 
cock have held that those parts of the brain supplied by the vertebral 
arteries were the seat of the emotions. Fothergill reminds us of the fact 
that we may have functional derangement of the liver without afiection 
of the intellect, but with depressed emotional states. There are other 
forms of abdominal trouble, such as an overloaded rectum and uterine de- 
rangement, which coexist with melancholia and depression of spirits, and 
every practitioner has seen the wonderful elation of spirits which follows 
a free movement of the bowels after continued torpidity of the liver. The 
extension of the cerebral vaso-motor, and the involvement of other areas of 
blood-supply may, of course, make the condition a more extensive one, 
and disturbances of motility and intellection naturally ensue. 

Pressure made upon the carotid or vertebral arteries by various tumors 
or growths, or sometimes by aneurisms, is a mechanical cause of cerebral 
anaemia of decided importance. I assisted at an operation several years 
ago where the carotid on one side was tied by Drs. Sands and Parker, of 



CEEEBRAL ANEMIA. 131 

this city. In less than twenty-four hours the patient died from extensive 
anaemia, owing to the failure of compensatory supply. Embolism is per- 
haps the simplest example of a cause of this kind. A detached vegetation 
or clot is washed into the circulation, up through the left carotid and into 
the middle cerebral artery for instance, cutting off the circulation, and 
producing extensive cerebral anaemia on the left side, while right hemi- 
plegia and aphasia follow. In thrombosis the artery is narrowed by the 
gradual deposit of plastic substances until finally its calibre is occluded, 
and the blood must tak« some other channel or not reach the part which 
it normally supplied. • 

Apoplexy, or brain tumors of various kinds, and atheromatous narrow- 
ing of cerebral arteries, are also direct causes. In the first two instances 
pressure is made directly on the brain substance, and in the latter there 
is a gradual change in the vessels themselves. 

As a familiar illustration of how cerebral anaemia may be produced by 
a drain upon the general vascular system, I may allude to the case of a 
patient whose trouble dated from a series of miscarriages occurring within 
a very short period. One of these happened when it was impossible to 
procure medical attendance, and she lost a great quantity of blood. 

After the last event she never completely recovered, and her present 
disagreeable and annoying condition remained. She was drowsy, had 
frontal headache, ringing in the ears ; was constipated, etc. Another pa- 
tient was subject to attacks of despondency, when life seemed very dis- 
tasteful and gloomy. Her appearance was characteristic. White skin, 
cold hands, palpitation, and other symptoms enabled me to diagnose ce- 
rebral anaemia, and vomiting and vertigo were confirmatory symptoms. 
The cause was found to arise from very troublesome hemorrhoids. After 
cauterization and removal, she regained her previous health. 

Certain medicinal agents, as well as tobacco, produce cerebral anaemia. 
The bromides undoubtedly possess this property, while chloral and chlo- 
roform, if taken for a long time, as they often are, are likely to provoke 
an anaemic state of the brain which is distressing in the extreme. I can 
recall the case of a young lady who confessed that she had been in the 
habit of putting herself to sleep at night with chloroform, besides inhaling 
it several times during the day. I have never seen such a typical case of 
this morbid condition. Her skin was of a hue of waxy whiteness, her 
pulse small and fluttering, her pupils widely dilated, and her languor 
and muscular feebleness very profound. Depression and the contempla- 
tion of suicide prompted her to confess her bad habit. Tobacco, though 
only affecting the heart, through its interference with pulmonary func- 
tions, undoubtedly produces in some individuals a condition of cerebral 
anaemia. The clammy, white skin, giddiness, dilated pupils, hurried 
respiration, and unsteady, weak pulse, and not uncommonly syncope, at- 
tendant upon nicotine poisoning, are, I think, evidences of cerebral anae- 
mia. Certainly the after effects are clearly suggestive of this morbid 
cerebral condition. That tobacco, in many individuals, in fact the great 
proportion, possesses stimulating effects, there can be no doubt ; but the 



132 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

variation of effects which follows the administration of opium, for exam- 
ple, when there is some idiosyncrasy, clearly leads us to infer that its ac- 
tion is sometimes different from that determined by the majority of phy- 
siologists. Physostigma, veratrum, aconite, and like cardiac sedatives 
may be mentioned as other ansemiants. 

Various conditions, such as lithiasis, are sometimes unsuspected, but 
nevertheless very important causes of cerebral anaemia. 

Morbid Anatomy and Pathology. — As we might expect, the 
anaemic brain is white, firm, reduced in bulk, and greatly changed. The 
vessels are empty, and there are no puncta visible when a cut is made 
through the white matter. We may find a distension of the perivascular 
spaces, the ventricles, and arachnoid spaces by fluids, and occasionally 
some thickening of the neuroglia. 

I have spoken in another chapter of the circumstances which modify 
the cerebral circulation. It only remains for me to refer to the experi- 
ments of Kussmaul and Tenner, Burro wes, and others, who have devoted 
a great deal of attention to the experimental study of this subject. The 
experiments of the first two observers were made upon six adults and a 
number of rabbits. When the carotids of the human subject were 
compressed, pallor, loss of consciousness, slow respiration, and dilated 
pupils were produced, which disappeared when the pressure was remitted, 
and could again be produced at will. Tying of the carotids was followed 
by convulsions, unconsciousness, and death, when post-mortem examina- 
tion revealed evidences of softening. 

^ In the first experiments, when pressure was remitted, there were evi- 
dences of a secondary cerebral hypersemia with flushing of the face. Ob- 
struction of the artery on one side may produce loss of motor power on 
the other, with immediate giddiness, loss of consciousness, syncope, and 
occasionally vomiting. There may be complete recovery after such an 
accident, but " it is always imperfect when the obstruction is situated on 
the further side (from the heart) of the circle of Willis."^ The obstruc- 
tion of the minor cerebral arteries, is followed by less complete intellec- 
tual derangement, by more marked vomiting and giddiness. Should the 
anaemia be quickly produced, as it is when severe injuries have been re- 
ceived and the patient literally " bleeds to death," convulsions form a 
prominent and almost constant symptom. Sighing respiration, and the 
other phenomena I have already named, are also expressed. 

In cerebral anaemia there is impairment of functional activity, while in 
congestion the reverse is the rule. Post-mortem examination shows that 
the brain in cerebral anaemia is white, condensed, and less bulky, and the 
vessels are empty. 

We have already cited the causes of cerebral anaemia, and it now re- 
mains for us to consider the part they play. Cerebral anaemia depends 
upon — 

^ H. Jones, Functional Nervous Disorders, p. 66. 



CEREBRAL ANEMIA. 133 

1. The insufficiency of cerebral blood-supply, througli actual defi- 
ciency. 

2. The action of certain agents upon the nerve-filaments themselves. 
It is hardly necessary to again more than allude to the first of these. 

In this condition the efiect of posture is said to greatly influence the cere- 
bral state. The erect position is conducive to an aggravation of the 
symptoms, while recumbency favors the flow of blood to the brain. This 
relief follows the supine position when the individual has an ordinary 
attack of syncope. Abercrombie relates a case which is quoted by Foth- 
ergill, and which is, I think, a beautiful practical example of this change. 
The patient, who was greatly reduced by some gastric disease, gradually 
became deaf, but heard perfectly well when he lay down or stooped for- 
ward. As soon as his face became flushed, the improvement in hearing 
began, and when he raised his head the blush faded away, and he relapsed 
into his old condition. Abdominal paracentesis is followed by syncope, 
if the patient is not made to assume the supine position, for during ascites 
the abdominal veins are so impinged upon that when pressure is remitted 
they are capable of suddenly receiving a very large quantity of blood — 
in fact, so much as to deprive the brain, and produce anaemia. A quan- 
tity of blood gravitates directly through the superior and inferior venae 
cav£e, not being thrown over by the right ventricle, but passing down 
into the abdominal vessels. 

Insufficiency of cerebral blood may be due to a powerless heart, or 
aortic insufficiency, that organ being unable to lift a requisite amount of 
blood for the nutrition of the brain. Not only may this be a direct re- 
sult of a weakened organ, but it may follow strong emotional excitement. 

This assumption of the recumbent posture is one of the best therapeu- 
tical means in certain cases. Dr. AYeir Mitchell has had extraordinary 
success in the management of certain intractable cases, some of which 
were directly dependent upon cerebral anaemia. 

Of the second mode of production, I may allude to the local effect of 
some blood poisons, and the influence of the emotions. Bearing in mind 
the important physiological law that section of the sympathetic is followed 
by vascular dilatation, and that irritation of the proximal end produces 
contraction, we are enabled to realize many of the pathological processes 
which occur in the production of cerebral anaemia. Anteriorly the vaso- 
motor fibres are derived from the superior cervical ganglion, and poste- 
riorly the fibres come from the inferior cervical ganglion. These fila- 
ments follow the course of the large cerebral vessels, and in this manner 
supply every part of the cerebral mass. 

This close relation with the vascular system explains the prompt action 
upon the heart of certain exciting emotions, and secondarily the varia- 
tion in blood-supply. This is the idea held by Fothergill and others, and 
most admirably explained by that writer in an article in the West Biding 
Reports} 

1 Art. Cereb. Ansemia, vol. iv., p. 108. 



134 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

The connection between variation in cell action and the function of the 
sympathetic fibres is, perhaps, the most interesting part of the sub- 
ject. Primarily the influence of impoverished blood affects the integ- 
rity of the cerebral nerve-cells, and secondarily the influence of the cere- 
bro-spinal fibres is suspended. I have no doubt that a certain train of 
symptoms, which is sometimes expressed during general anaemia, is the 
result of a temporary local hyperaemia, through paresis of thevaso motor 
fibres ; and that parts of the brain are congested while others are ansemic. 

A result of continued emptiness of the vessels is an oedematous condi- 
tion of the brain, from distension of the perivascular spaces by the cere- 
bro-spinal fluid. This condition is sometimes so extensive as to receive 
the name " serous apoplexy," and profound stupor is the result. 

In relation to sleep and its connection with cerebral ansemia, it will 
bewell to say a few words. A great many observers, among whom 
were Durham and Fleming, strongly held that the brain is ansemic 
during repose, the ancemia being the cause of sleep. Others have 
dififered with them; and experimental facts seem to favor this view 
of the case. Not only may anaemia be unattended by sleep, but a condi- 
tion of unconsciousness closely resembling healthy sleep may be the re- 
sult of a hypersemic cerebral state. Opium, alcohol, and various agents 
which increase the cerebral blood-supply, act in this way ; but the stupor 
which follows a toxic dose of either agent must not be confounded with 
natural sleep. Certain curious facts militate strongly against the ansemic 
idea, or, at least, against the assertion that sleep is directly dependent upon 
a diminution in the supply of blood to the brain. 

1. There are many ansemic individuals who sleep only after taking 
stimulants. I think all who have seen the good eflPects of a bottle of ale 
at bedtime will be disposed to take this view. The sleep produced in no 
way resembles stupor, and there is no disagreeable sense of fatigue in the 
morning. 

2. Dr. Janeway made an interesting experiment. This consisted in the 
administration of a few drops of nitrite of arayl to a sleeping person. 
Although cerebral congestion followed, the patient did not awake. 

3. If mental action is dependent upon activity of the cerebral circula- 
tion, and sleep upon anaemia, it almost seems that dreams must be incon- 
sistent with sleep ; while, on the contrary, many individuals enjoy the 
most vivid and constant dreams, and do not awake till their usual hour. 

I am more inclined to think that the production of sleep depends upon 
some change in the function of the nerve-cell, and that this modified form 
of action is not necessarily dependent upon either ansemia or congestion 
in any particular case, but that, if there be ancemia, it is secondary to the 
cell-change, whatever that may be. 

The connection of a torpid condition of the liver with cerebral ansemia 
will explain the constipation, which is anything but an uncommon accom- 
paniment of the disease. Intestinal accumulation, as Fothergill says, 
may " stand to cerebral ansemia in a causal as well as a consequential re- 
lationship," and he alludes to the experiments of Ludwig and Daziel to 



CEREBRAL ANEMIA. 135 

illustrate the connection. A finger passed over the intestines produced 
acceleration of the intracranial circulation. 

The general symptoms, such as languor, the various modifications of 
sensation, etc., are directly due to a diminution in nervous supply. 

Diagnosis. — Acute general attacks of cerebral ansemia may be con- 
founded with cerebral congestion, stomachic and auditory vertigo. I have 
already spoken of the distinction to be made between the disease under 
discussion and cerebral hypersemia, and it is not necessary to say more. 
Attacks of stomachic vertigo, or Meniere's disease, are symptomatized 
as follows: The first is characterized by a feeling of " emptiness of the 
head," reeling and swimming, general coldness; " objects whirl around ;" 
710 loss of consciousness, nor marked disposition to sleep. No dependence 
upon a very full or empty stomach, and the possible existence of gastral- 
gia. In Meniere's disease there is aural disease, and turning or whirling 
generally to one side, from left to right, and the condition is not continu- 
ous. The most important facts to discover are in relation to the cause, 
whether it be a secondary condition, the result of cardiac trouble, or 
whether it be simply a result of general anaemia, without any organic disease. 

Chronic cerebral anaemia presents various phases, and it is almost im- 
possible to go over the long list of general diseases which it may be a 
feature of, or, which, like hysteria, it may counterfeit. Cerebral tumor 
may give rise to symptoms which are really due to cerebral anaemia. So 
perfect is the resemblance that Dr. Hughlings Jackson told me recently 
that it would be impossible for him to make a diagnosis in many cases 
with any degree of certainty. 

Prognosis. — As cerebral ansemia is nearly always due to some cause 
which is easy of removal, the prognosis is goodr If, however, there be 
organic heart trouble, the case assumes a difierent aspect- Old cases are 
extremely discouraging, particularly when the patients happen to be 
women. Irritability and hysteria generally enter largely into the com- 
plaint, and treatment is sometimes almost useless. If uterine, hemor- 
rhoidal fluxes, and other such drains, exist, of course their amelioration is 
attended by cure. Should the loss of blood be caused by a cancerous 
uterus or rectum, the prognosis is consequently very bad. 

Treatment. — It is of the utmost importance that the practitioner 
should seek out and remove, if possible, such conditions as diminish the 
amount of blood in the body, and consequently he must ascertain the 
existence of hemorrhoids, uterine hemorrhages, either periodical or irre- 
gular, and apply appropriate remedies in such cases. Without ventur- 
ing upon another field, I would call attention to the necessity, in cases 
where there is monorrhagia, of overcoming this condition as promptly as 
possible, for special treatment of the nervous condition is of little avail 
when the woman every month loses a quantity of blood largely in excess 
of what is made in the interim. 

I have, of late, had encouraging success in the treatment of cerebral 
anaemia by means of nitrous oxide gas. 

This gas is essentially a nervous stimulant, and while its action is 



136 DISEASES OP THE CEREBRUM AND CEREBELLUM. 

somewhat like that of oxygen, it has the advantage of influencing the in- 
tellectual and emotional functions. 

The use, say of two gallons of gas mixed with one of air, will produce 
pulse quickening after two or three full inhalations, and such quickening 
will be attended by very slight flushing of the face, and throbbing of the 
temporal vessels. 

If the administration be carried sufficiently far a condition of tempo- 
rary unconsciousness results, which is attended by anaesthesia, and upon 
recovery, there is a certain amount of reaction. It is unnecessary to say 
that the extension of the efiects of the gas to this stage is entirely out of 
the question, and an extremely injudicious measure when the desire is to 
improve circulation and nutrition. 

Exhilaration of spirits is the rule after its use, not however, necessarily 
amounting to the abandon that so often follows the lecture room experi- 
ments of ten or fifteen years ago, but sufficient to indicate a very decided 
activity of ideation and the emotions. Melancholic and taciturn sub- 
jects became animated and cheerful in their address and behavior. One 
of the patients, of the late Dr. J. Ellis Blake who first used the gas in 
America as a therapeutical agent in nervous disease, declared that the 
figures upon his ledger bore an entirely different import after he had 
taken his dose of gas, and walked to his office, and the debit side looked 
wonderfully less depressing. In another case, the patient who had left 
home quite reluctantly, and desired at first to go back immediately, forgot 
all his worriments after the first two or three days of treatment. It is cer- 
tain that in hypochondriacal patients many minor aches and pains are 
forgotten, and a general eouleur de rose tinges everything. 

My attention was forcibly drawn to this effect upon certain patients 
after I had used it with melancholies, both in my private practice and at 
the Insane Asylum at Blackwell's Island. One of these had suff(ered for 
several weeks from the most profound despondency. Her trouble had 
grown out of menstrual irregularity, and was evinced by religious delu- 
sions of a mild type, inclination to avoid the society of her friends, and 
an occasional refusal to eat. The use of the gas for several weeks en- 
tirely removed her mental trouble, and she became quite cheerful. In 
the presence of Drs. MacDonald, Pitkin, and Lesynsky, nitrous oxide 
was given to two melancholic patients at the Female Insane Asylum who 
had refused food, and had not eaten voluntarily for two weeks. 
Both of the women went to the table and ate heartily the same even- 
ing. 

In other cases of melancholia with defective surface circulation, the 
venous stasis which gave the hand a dusky purple color disappeared in 
a few days to a great extent, and the white mark which remained after 
pressure of the finger upon the back of the hand had been remitted, did 
not last nearly so long, nor was it so sharply defined as under other 
circumstances. The warmth of the extremities was decidedly in- 
creased, and the expression of the eyes was brighter, and much more in- 
telligent. 



CEREBRAL ANEMIA. 137 

Mitchell ^reports seven cases of melancliolia, mania and dementia 
treated with nitrous oxide, in all of whom interesting effects were wit- 
nessed. The gas was not administered however, for its stimulant effects 
alone, but given until the point of partial unconsciousness was reached. 

Active measures are necessary when there is general anaemia, and for 
this purpose we must resort to iron, strychnia, phosphorus in some of its 
forms, cod-liver oil, an abundance of nutritious food, with stimulants such 
as milk punches, porter, or ale. 

A word or two is necessary in regard to the diet, and the quantity of 
alcohol given to these patients. It is the physician's bad fortune to meet 
with cases of this kind in which digestive troubles are dependent entirely 
upon an enfeebled state of the viscera, and we should therefore use great 
care and not be impatient. A hearty regimen, and too much alcohol, 
may do mischief instead of good. It is well, therefore, in certain cases, 
to give the stomach as little work as possible, and at the same time to 
allow it to exert itself in a way that will most benefit its possessor. A 
very little food, given at short intervals, will be more perfectly digested 
and assimilated than a large quantity taken at long intervals. I have 
often given a few table-spoonfuls of cream or beef-juice every hour for 
days, and have ultimately seen such a marked improvement and an in- 
creased capacity for work upon the part of the digestive organs, that the 
more gross varieties of animal food, as well as alcohol, were after a while 
borne in large quantities. Should this enfeeblement of the digestive 
organs exist, we may give either pancreatine emulsion, or strychnia and 
muriatic acid. Extract of malt is sometimes very well borne, and hastens 
the improvement. This may be given in combination with codliver oil. 

One of the most useful forms of treatment to which I have already 
alluded — the " rest treatment " of Weir Mitchell — is of marked service 
in old cases, especially if the subjects happen to be women. Dr. Mit- 
chell has treated many cases which are almost identical with those that 
generally come under the head of chronic cerebral ansemia. He says : 
" These cases vary, of course, endlessly ; but their essence is a state of 
reduced nutrition, which no mere tonic will cure, while they are afoot 
and living on their capital. The main symptoms are the state of painful 
tire, the low temperature, the great or less anaemia, the quick pulse, the 
excess of white blood." He calls attention to the necessity for perfect 
quiet, and at the same time daily massage and faradization of all the 
muscles. His treatment is expressed in his own words thus : " The 
amount of feeding, of massage, and of faradic-muscle exercise which each 
case will bear and prosper under, is a matter to be told early in the case 
by watching the pulse, the temperature, and the appetite. In these cases 
the pulse is always rapid. If it fall, if the temperature rise, above all, 
if there be the least gain in flesh, I know that I am on the right path 
and am not moving on it too fast ; but if these symptoms be reversed, and 
if the patient ceases to be hopeful and looks weary, then I lessen the pas- 
sive exercise, and wait a little ; but, above all, I listen to what my 

1 W. R. Eeports. 



138 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

masseur or masseuse tells me of the ease with which the limbs flush or 
the readiness with which the muscles grow firm under the kneading 
fingers, for in this matter I get to have a very shrewd judgment. As to 
the rectal feeding, which I rarely omit, I say little, as it is well under- 
stood. It should always include cod-liver oil. There is only this to be 
borne in mind : most medical men feed by the bowel when they cannot 
by the mouth. I like to use both ends at once." 

This treatment seems to be the very best in cases of long stand- 
ing ; but it is well to see first what fresh air, tonics, and abundant 
nitrogenous food will do for our patient, while she pursues her ordinary 
life. 

The selection of a climate for the nervous patient is a matter of great 
importance. Dr. Denison, of Denver, who has written much upon this 
subject, and who has lived in Colorado, speaks with some caution regard- 
ing the benefits of high altitude. He says : " The more acute or severe 
the nervous symptoms, the more of an aggravating nature is the efiect of 
an elevation."' He does not recommend Colorado for patients who sufier 
from epilepsy or cholera, but only in such cases where the diseases of the 
nervous system depends upon certain dyscrasia. Organic diseases are 
aggravated. In cases of nervous exhaustion with ansemia and depres- 
sion, there can be no doubt of the advantage of the stimulating climate 
of Colorado, and to such a place we might send our patients, expecting 
great benefit. 

STOMACHIC VERTIGO. 

Synonyms. — Vertigo a stomacho Iseso (Lat.) ; Vertige stomacal 
(Fr.) ; Gastric vertigo. 

Definition. — A condition of giddiness, hallucination, nausea, head- 
ache, etc., without loss of consciousness, and probably dependent upon a 
reflex excitation of the cerebral vessels from some visceral irritation. 

Symptoms. — The condition, which is a very common one, is pro- 
duced, in most cases, directly after a hearty meal, or else when the stomach 
is entirely empty. A sense of gastric fulness at first, while headache, 
with buzzing in the ears, palpitation, and giddiness of a few moments' 
duration, follow. Should there be hallucinations, the patient is not wor- 
ried by them, but realizes their unsubstantial character. Trousseau^ in- 
sists upon the fact that the hallucinations of this condition differ from 
those attendant upon cerebral hypersemia from the fact that in this form 
they do not occur when the head is lowered, which is the case in cerebral 
hypersemia. 

Causation. — Stomachic vertigo is more a condition of middle life and 
old age than one of youth. Young women occasionally suffer, but this 
is the exception. Certain forms of indigestible food may directly pro- 

^ Eocky Mountain Health Eesorts, p. 145. . 
' Clinical Medicine, Am. edition, vol. ii. p. 358. 



AUDITORY VERTIGO. 139 

yoke the attack, or it may follow violent exercise after a hastily eaten 
meal. In one case of which I know, a gentleman ran for over a mile to 
catch a morning train. He had arisen but a few moments before, and 
had hurriedly eaten his breakfast. He fell to the ground, but did not 
lose consciousness. The disorder often occurs when the individual has 
been eating irregularly ; and business men or others who take but little 
exercise and eat hurriedly are very often the sufferer^. Handfield Jones^ 
considers taenia to be a frequent cause of vertigo, and such has been my 
own experience. 

Treatment. — Trousseau, who has written most fully upon the sub- 
ject, recommends that the patient be directed to drink every morning a 
glassful of quassia infusion made by maceration of the shavings in water, 
or to use the goblet of quassia wood in which the water is allowed to re- 
main until it has become bitter. After each meal one of these powders 
should be taken : — 

R. Sodae bicarb., 

Magnesise calc, aa gr. xv. 
Cretse prsep. ^&s. — M. 
Divid. in chart, no. iij. — Sig. One after each meal. 

Strychnia, pepsine, and sometimes bismuth are excellent remedies, and 
should be given, while attention is to be paid to the patient's general 
habits. 

AUDITOKY VERTIGO. 

Synonyms. — Labyrinthine vertigo ; Meniere's disease. 

Definition. — A morbid cerebral condition expressed by vertigo and 
rotatory movements, unattended by loss of consciousness, and dependent 
upon disease of the labyrinth, or other parts of the central auditory appa- 
ratus 

To M^niere^ belongs the credit of having first accurately described this 
disease, though Triquet^ gives the credit of its discovery to Saissy, of 
Lyons, who observed a nervous condition connected with diseases of the 
inner ear. Trousseau* says that Saissy did not mention vertigo as a 
symptom of the condition to which he called attention. It is enough to 
say that, prior to 1861,' the form then known only as stomachic vertigo 
was always supposed to arise from digestive troubles, and the existence of 
a distinct variety, with aural disease, was not appreciated. 

Symptoms. — Generally there are some indications of otitis, whether 
they be simple inflammation denoted by pain, or a discharge of bloody 
pus, or even perforation of the tympanum. In many cases the disease 

^ Functional Nervous Disorders, p. 444. 

2 Bulletin de I'AcaderaLe de Med., xxvi. p. 241. 

^ Leyons cliniques sur les Maladies de I'Oreille, p. 113, Paris, 1863. 

* Loc. cit., p. 363. 



140 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

may be preceded by a chill, and this should be always looked upon as a 
serious indication. The patient is suddenly seized with vertigo, and at 
the same time experiences a feeling of nausea and buzzing in the ears, 
which may be double, or confined to one side. This vertiginous condi- 
tion calls to mind a sensation experienced when one is twirled in a swing. 
A boyish prank is to twist the ropes of a swing while the unhappy victim 
is seated therein ; then to suddenly release the board, which revolves with 
great rapidity as the ropes unwind. This description of the symptom was 
given me by a patient who suffered from nausea at the same time with 
vertigo. The vertigo is attended by a loss of equilibrium. The patient 
sways or reels, and there is an impulse to turn from the left to right when 
the left ear is affected, and vice versa when the other is the seat of the dis- 
ease. Ferrier^ describes a sensation usually experienced. He (the pa- 
tient) feels " as if he were suddenly lifted from the ground and pitched 
forward and to the right side." There is also a tendency, when walking, 
to keep close to the side of the wall or house which corresponds to the 
affected ear. Deafness is generally present, but this is, of course, the 
result of the destructive aural disease.^ Recovery is not always to be ex- 
pected, but a great many cases improve under appropriate treatment pre- 
sently to be described. 

John B., aged 47, iron railing manufacturer. Nearly eighteen months 
ago, he became troubled by noises in the left ear, which he compared to 
the " singing of canary birds," and afterwards this subjective noise 
changed its character, and he described it as a continuous roaring like 
the escape of steam from a boiler. To this sound he has since become 
partially accustomed. He has never had earache, but nine years ago there 

^ Labyrinthine Vertigo, W. K. Reports, vol. v. p. 34. 

2 Cruni-Brown is of the opinion that, in addition to the other senses, the individ- 
ual possesses one of rotation, by which we are able to determine the axis about which 
rotation of the head takes place ; the direction of rotation, and its rate. In explain- 
ing some experiments performed by him, he says: ''In ordinary circumstances we 
do not wholly depend upon this sense for such information. Sight, hearing, touch, 
and muscular sense assist us in determining the direction and amount of our motions 
of rotation, as well as of those of translation ; but if we purposely deprive ourselves 
of such aid, we find that we can still determine with considerable accuracy the axis, 
the direction, and the rate of rotation. The experiments that I have made with the 
view of determining this point were conducted as follows: A stool was placed on the 
centre of a table capable of rotating smoothly about a vertical axis ; upon this the 
experimenter sat, his eyes being closed and bandaged ; an assistant then turned the 
table as smoothly as possible through an angle of the sense and extent of which the 
experimenter had not been informed. It was found that, with moderate speed, .and 
when not more than one or two complete turns were made at once, the experimenter 
could form a tolerably accurate judgment of the angle through which he had been 
turned. By placing the head in various positions, it was possible to make the verti- 
cal axis coincide with any straight line in the head. It was found that the accuracy 
of the sense was not the same for each position of the axis in the head ; and, further, 
that the minimum perceptible angular rate of rotation varied also with the position 
of the axis. It was also found that considerable difierences of accuracy exist in dif- 
ferent individuals." 



AUDITORY VERTIGO. 141 

was a discharge from the left ear, but there have since been no other 
symptoms. He has suffered for a long time from post-pharyngeal catarrh, 
and there is now a catarrh of both Eustachian tubes. When a young 
man he had secondary syphilitic symptoms, but denies having had any 
primary sore. Sixteen months ago, during hot weather, he was seized in 
the street with dizziness and reeling, and was obliged to grasp a lamp- 
post for support. There was no loss of consciousness, and he realized 
fully his condition of helplessness. He said that he felt as if he was be- 
ing "twirled" from right to left, but did not fall. This attack occurred 
before dinner (about 11 A. M. ), and his stomach was neither filled nor 
completely empty, for he had eaten his breakfast at 8 A. M. He was 
perfectly well otherwise, and the only disordered function was that of the 
lower bowels, for he was constipated. He has had these attacks very 
frequently. For the six months following the first attack of vertigo they 
occurred about once a month, but since then they had been of daily re- 
currence. 

Present State. — The patient's digestive organs are in good condition, 
and his appetite is fair. He is ordinarily of constipated habit, but it re- 
quires but slight medication to overcome this. He is of medium height, 
weighs 143 pounds, and seems a well-nourished man. His face is some- 
what suflused when he becomes excited, but he is ordinarily pale. His 
eyes convey an anxious expression, but the pupils are normal. His hair 
is scanty and gray, but not removed in patches, nor suggestive of any pre- 
vious syphilitic trouble. He has occasional headache, and still complains 
of the " roaring" noise on the left side. Hears the tick of a watch only 
six inches from left ear, and indistinctly at any distance within this limit. 
Watch tick heard at five inches from right ear, but more perfectly. Dr. 
C. S. Bull examined his eyes, and the following is his report : — 

20 20 

" Examination of J. B. V= : with convex 32 spherical V= — — 

40+ ^ 40+ 

1 
H — . Fundus perfectly normal." 
30 

His attacks occur nearly every day, and seem to have no relation with 
the condition of digestion. These " reeling fits " may take place at any 
time of the day, last for five or six minutes, and usually are not so 
sudden as to prevent him from taking hold of the nearest lamp-post or 
railing. In a recent vertiginous seizure he was taken just as he was about 
to get into a street car, and would have fallen had the conductor not 
dragged him upon the step. He tells me that he has asked his wife to 
" turn him the other way " when the attack occurs, and usually this has 
the effect of a"bating it. I placed him upon large doses of quinine at first, 
which- have decidedly influenced the frequency and character of the ver- 
tigo, so that he often passes a week at a time without any seizure. Bro- 
mide of potassium had been prescribed for him before his visit by another 
physician, but he tells me that this drug increased the dizziness. The 
phenomena of these attacks are the following : He suddenly feels light 
headache ; objects swim about him from right to left while he seems to 
be rotated the other way, and during this period he separates his feet 
and braces himself. The outlines of the houses, trees, and sidewalks are 
blurred and distorted, and after a few minutes they suddenly assume 
their proper relations, and the attack passes off, and he has subsequent 
headache. 



142 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

Causes. — The disease being directly due to aural inflammation, and the 
causes of this condition, whether they be exposure, the extension of other 
inflammatory processes, or the injudicious use of douches and injection, 
are only secondarily productive of the neurosis. 

Pathology. — The experiments of Flourens and Goltz^ have been the 
basis for our pathological study of Meniere's disease. Brown-Sequard ^ 
and Flourens demonstrated that when the membranous canals of the 
labyrinth were divided, various disturbances of equilibrium followed. 
AYalter and Ltncke^ and others have divided the horizontal canals and 
produced oscillation of the eyeballs, swaying of the head from one side 
to the other ; and have seen the animal spin round like a top. Division 
of the posterior vertical canal causes the animal to topple over backwards, 
and the head is moved backwards and forwards. When the superior ver- 
tical canals were cut across, the animal pitched forward. It may be seen 
that a diseased condition, not limited to any particular spot, may produce 
a combination of these symptoms. 

Brown Sequard, in speaking of the relation of rotary movements to 
auditory irritation, calls attention to these familiar illustrations : — 

" 1st. Any one who has received an injection of cold water in the ear 
may know that it produces a kind of vertigo, and that it is difficult to walk 
straight for some time after this irritation. 2d. A sudden noise makes the 
whole body jump, particularly in old people, or in persons attacked with 
ai.semia, chlorosis, epilepsy, chorea, hysteria, hydrophobia, and in certain 
cases of poisoning ; in a word, in all circumstances in which the control of 
the will over reflex actions is lost or diminished. 3d. Vertigo and various 
convulsive movements in cases of irritation of the acoustic nerve have 
been observed in adults and children. Rotatory movements have taken 
place in cases of suppurative inflammation of the ear, and twice imme- 
diately after an injection of nitrate of silver." Ferrier,* who has written 
most clearly upon this disease, goes very deeply into the subject. In the 
normal state it is necessary for tactile, visual, and auditory impressions to 
be unembarrassed, so that the power of equilibriation may be preserved ; 
but it is of absolute importance that the labyrinthine functions should be 
perfect. It seems to regulate the state of equilibrium of the individual, 
and to preside over co-ordination. The mechanism of the labyrinthine 
canals is admirably described by Crum-Brown.^ The sense of rotation, 
as suggested by him, must, like other special senses^ have a special peri- 
pheral organ, a brain centre, and a connecting sensory nerve. All experi- 
menters agree that the labyrinth is a special peripheral organ, and the 
auditory nerve is that which conveys the peripheral irritation to the centre. 

^ Pfluger's Archiv fiir Physiologie, 1870, and Eecherches sur les Propr. et les 
Fonctions du Systeme Nerveux 2d. ed. 

^ Central Nervous System, Philadelphia, 1860, and Experimental Researches, 
1853. 

^ Wagner's Handworterbuch der Physiol., vol. vi., 1853, p. 420 et seq. 

* Ferrier on the Functions of the Brain, New York, 1876. 

^ Journal of Anatomy and Phys., May, 1874. 



AUDITORY VERTIGO. 143 

" The bony canals are filled with liquid, in which float loose connective 
tissue, and the membranous canals with the contained endolymph. nota- 
tion of the head about an axis at right angles to the plane of a canal will 
then produce, on account of the inertia of the liquid, etc., motion of the 
contents relajtively to the walls of the canal ; and this may be expected to 
irritate the terminations of the nerves in the ampulla. If the rotation be 
continued at a uniform rate, fluid friction of the endolymph against the 
membranous canal, and of the perilymph against the membranous canal, 
and the periosteum will gradually diminish this relative motion, which will 
at last cease. We should therefore expect, as we have seen to be the case, 
that continued uniform rotation should be perceived less and less strongly, 
and that the sensation should at last die away altogether. The time re- 
quired for this equalization of the motion of the canal and its contents will 
depend upon the rate of rotation and upon the dimensions of the canal 
and the aoaount of attachment of the mimbrauous canal to the periosteum. 
These latter conditions are not the same in the three canals, and there- 
fore we ought to find, as we do, that the rate at which the sense of rotation 
dies away is not the same for different positions of the head. Again, if 
the uniform rotation is stopped, the contents of the canal will continue to 
move on, thus causing an apparent rotation in a direction the reverse of 
that of the original rotation, and this also will die away owing to friction." 
The' irritation of the auditory nerves which occurs is attended by anaemia 
of certain parts of the brain, which accounts for the reeling, dizziness, 
nausea, and other symptoms with which we are already familiar. 

Diagnosis. — Gowers,^ in a paper before the British Medical Associ- 
ation, pointed out the liability of its confusion with gastric trouble. He 
calls attention to the fact that violent and repeated vertiginous attacks, the 
sense of movement or actual turning, tinnitus aurium, and, deafness, are 
more suggestive of the auditory origin than of gastric vertigo. Gowers' 
cases were connected with affections of smell and taste, and at the same 
time in one there was a gastric ulcer. He made his diagnosis by the de- 
tection of loss of function of the right ear and by one-sided falling. It is 
often necessary to differentiate from petit mal, from apoplectic warnings, 
and from general cerebral anaemia. In the first there is rarely vertigo, 
but there is loss of consciousness of temporary duration, and there is some 
convulsive movement, though sometimes so slight as to be unrecognized. 
The presence of aural disease is enough to throw out of the question the 
other condition I have named. 

Treatment. — Large doses of quinine have been of service in these 
cases, and Charcot's^ experience with this agent is extremely gratifying. 
He recommends the energetic use of revulsives in vertigo, the cautery 
being applied over the mastoid bone three or four times a week. He 
gave sixty centigramme doses of quinine in one case for a period of two 
months with happy results, and a short time after the commencement the 

1 Br. Med. Journal, Aug. 26, 1876. 

- Lepons sur les Maladies du Syst. Nerv. No. 4, p. 321. 



144 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

vertiginous attacks ceased. It is necessary to give the drug in large 
doses, and at the same time the aural disease should not be neglected. 

In the case of " J. B." I combined infusion of digitalis with the quinine, 
and obtained very good results. He was also directed to turn in an op- 
posite direction to that caused by the disease. Subsequent experience has 
convinced me that strychnine is perhaps better than quinine, and I have 
been highly successful in relieving a case of much greater violence in 
which increasing doses of the drug were administered. In this connec- 
tion it will be well to call attention to attacks of malarial vertigo of a 
periodic character which are sometimes encountered, and which resemble 
auditory vertigo : quinine or arsenic is of course indicated. 



INTRACRANIAL THROMBOSIS. 145 



CHAPTER IV. 

OCCLUSION OF INTKACRANIAL VESSELS. 

THROMBOSIS— EMBOLISM. 

The deprivation of an area of greater or less extent of its blood-supply 
constitutes a condition which has been called by some writers " Local 
cerebral anemia," and it may take place through the existence of either 
of the above vascular states. Though very closely allied, these two 
forms of mechanical obstruction may be defined : in one case, as the local 
formation of deposits, or morbid changes favoring obliteration of blood- 
vessels ; and in the other, as the lodgment of clots, or organized tissues 
which have been brought from a distance. Their chief interest lies in 
the fact, that it is often difficult for us to distinguish the subsequent 
symptoms from those indicating an effusion of blood from a ruptured 
vessel ; that speech troubles are prominent ; and that the prognosis is 
nearly always unfavorable. Thrombosis and embolism, though usually 
followed by many of the same symptoms, and confounded with each other 
by some of the medical writers by whom they were first described, differ 
greatly in their manner of occurrence and pathology. The first, as we 
shall hereafter see, is of slow development, and is not so serious in its re- 
sults as embolism, while the latter condition is much more grave in all 
its features. 

INTKACRANIAL . THROMBOSIS. 

Any local vascular change from the normal state which favors the de- 
position of fibrine in an intracranial vessel, whether it be an artery, a 
vein, or sinus, produces the condition which is known as thrombosis. As 
a consequence, the calibre of the vessel is narrowed, and circulation of 
blood is impeded therein ; clots form, and either from actual obstruction 
of direct supply or by pressure, a region of greater or less extent becomes 
ansemic. Though the arteries are more frequently the seat of such an al- 
teration, the veins and large sinuses and the capillaries may be plugged 
up by clots which are of local origin. The condition, however, last men- 
tioned is fortunately a very rare one, but when it is met with it is a most 
dangerous and alarming morbid state. 
10 



146 OCCLUSION OF INTRACRANIAL VESSELS. 

THROMBOSIS OF THE CEREBRAL ARTERIES. 

Symptoms. — It is a disease of slow development, and may affect 
several arteries simultaneously, or but one. For weeks, or even months 
before, distressing and important evidences appear, and the patient may 
present unmistakable expression of the cerebral change, such as head- 
ache, which is generally localized, confusion of ideas, and awkwardness 
of speech, these disturbances being, usually, varieties of aphasia. As the 
disease advances, this trouble becomes much more pronounced, and, in 
place of there being simply a difficulty in expressing a clearly originated 
idea, there may be a condition of amnesia. Clumsiness of speech, and 
want of delicacy in articulation are followed by an actual failure in re- 
membering words. Memory is also defective in other things, and one 
patient begins to become stupid and listless. The next indication of this 
advance may be the appearance of paralysis, which is sometimes slight, or 
incomplete, only involving the muscles of the face or eyeballs, or there 
may be hemiplegia. Should the thrombus be seated in a large artery, or 
softening occur, a complete and. lasting hemiplegia may be produced. 
There is rarely loss of consciousness at any time, and in very few of the 
cases that recover, is there anything at all like the paralysis following 
cerebral hemorrhage. 

Recovery is generally to be looked for, provided the vessel be not an 
important one ; and, though like its first cousin, embolism, it may be one 
of the causes of softening, such a termination is not always to be feared. 
Aphasia, which is insisted upon by most writers as a pathognomonic sign, 
is occasionally absent. In one case reported, though the left middle cere- 
bral was affected, there was no aphasia at any time.^ 

The following case is one that came under my observation, and is of 
interest, because of the seat of the thrombus, and the interesting character 
of the morbid appearances : 

L. C, aged 22 years, seamstress ; admitted into hospital October 9, 
1876. History from friend who accompanied her. The patient had been 
feeling unwell for about two months, having had pains in her head and 
back, loss of appetite, insomnia, and other troubles. About a week ago 
the friend went up to her room to assist her to dress for breakfast. When 
the patient stepped out of bed she fell upon the floor, and then first no- 
ticed that she was completely paralyzed on the right side. The friend 
knew nothing of the patient's antecedents. Her husband, who was seen 
subsequently, stated that he had left her because she drank ; and that 
after the separation she went to New York and became a prostitute. 
Two years ago he saw her, and at that time she had marks of syphilis on 
her face, and her hair was falling out. She conversed with him intelli- 
gibly, but said she was suffering from " general debility." She had head- 
ache, pain in the back, etc., and was at this time leading a very irregular 
life ; sitting up during the greater part of the night, and sleeping only 
a portion of the day. She went to Ward's Island for treatment. The 

1 St. George's Hospital Eeports, vol. i., 1866,- vol. vi., p. 322. 



THEOMBOSIS OF CEEEBRAL ARTERIES. 147 

following history was taken by Dr. Naylor, resident physician in hos- 
pital : — 

Oct. 10. Complete hemiplegia of the right side, limbs lax, and muscles 
flabby ; impossible to excite reflex movements by tickling ; right pupil 
irregular, and smaller than the left ; tongue drawn to left side when pro- 
truded, and when she laughs the right side of the face is drawn up. Con- 
trol over the sphincters good ; temperature 101° ; patient aphasic. When 
asked, " How long have you been sick ? " replied, " Since Benny ; " this 
answer was given to many questions asked. " What do you hold in your 
hand ? " (it was a piece of bread.) " Tobacco." Seemed puzzled, but 
when reminded of its true nature she brightened up and appeared to real- 
ize her mistake. 

ISth. In about the same condition. Muscles of the right arm and leg 
do not respond to the currents. When asked how old she was, replied, 
" So and so." " What did you work at ? " "So and so." " What street 
did you live in ? " Appears puzzled. " Was it sixteenth f seventeenth f 
eighteenth f " " Yes." " How long has it been since you last saw your 
mother ? " " You long so, John." Expression intelligent, and she seems 
to understand all that is said to her. Does not hear so well on left side, 
with right ear perfectly. 

Vlth. Appeared to be sufiering great pain. When asked to locate the 
pain, she did not attempt to do so. She has passed no urine since yester- 
day morning. Has a hard and swollen erythematous spot on the outside 
of each knee, and two similar enlargements on each leg below. There is 
a hardened red spot over the fourth cervical vertebra. All of these parts 
are painful to pressure. 

\%th. Right hand somewhat swollen. 6 P. M. Is drowsy this evening. 
Appears to suffer pain, and places left hand upon abdomen. One pint of 
straw-colored urine containing no abnormal constituents was drawn by the 
catheter. 

V^th. Still dull and drowsy. Said nothing to-day but "yes," " no," and 
" well ;" passed her urine in bed ; stupid and dull all day. Carotid on 
right side pulsates very distinctly. 

21st Somewhat brighter to-day ; bowels regular. 

22d Relapse to stupid condition ; passed urine in bed ; became choked 
while eating some beef at dinner. 

25^/i. Still absolute loss of power and sensation on right side, and con- 
tinued drowsiness. 

26^/fc. Involuntary discharges of feces and urine. 

Tith. She brightens up after receiving nourishment, but cries and seems 
distressed. 

28^/^, 2 P. M. Nurse called the house physician, seeing that she appeared 
to have stopped breathing. Her eyes were turned upwards and her lips 
blue, and her pulse was very weak and feeble. Ordered stimulants. 

Nov. 2d. Feverish and restless ; temperature 101° ; discharges from the 
bowels have stopped. 

Qth. Complains of pain in her thigh and legs ; cries a great deal ; re- 
fuses food, and appears to be very much run down. 

8th. Right pupil approaching more nearly the size of the left ; appetite 
still good ; bowels regular. Cannot write her name with the left hand, but 
makes a disorderly scrawl. Asked her to repeat several words ; pro- 
nounced " eggs " very distinctly ; for " cross," she said " cork." 7 P. M. 
Quite feverish and restless; temperature 102°. 



148 OCCLUSION OF INTKACRANIAL VESSELS. 

13^/t. Has still fever ; temperature 102"^. Ordered quinine and cold 
sponging She cries, and appears very sensitive when moved. 

Uth. Slept well last night. 7 P. M. Temperature 100°. Several in- 
guinal glands on the right side are somewhat enlarged and painful on 
pressure. 

22d. Complains of great pain at the attachment of the adductors to 
femur. 

The month of December was passed without anything occurring of spe- 
cial note. The patient grew much more feeble ; there was no improve- 
ment in the paralysis, and she became reduced to a shadow. The tempera- 
ture continued elevated, and she was restless and delirious at times. Of 
course the burden of her delirium consisted of two or three words, which 
were repeated over and over. 

Jan. 8, 1877. Dr. Naylor was called to see the patient at 4 o'clock P. 
M. He then noticed some fibrillary contraction about the right angle of 
the mouth, with an occasional spasm of the upper lip, when it would be 
drawn up with the wing of the nostril. Eyes closed, pupils more con- 
tracted than usual, face flushed and head hot; temperature in axilla 101i°. 
When left foot was pricked she turned it up ; pulse too rapid to count ; 
heart's action tumultuous. Tr. digitalis, gtts xv. 5 o'clock P. M. Spasm 
of lip still continues ; lies on her back with eyes closed, and gives no evi- 
dence of pain when any part of the body is pricked ; pulse in same state. 
6 o'clock P. M. Breathing heavily ; eyelids closed and eyes turned up- 
ward ; pupils do not contract to light, but lids contract slightly when con- 
junctiva is touched; reflex irritability very much impaired; pulse 100 ; 
temperature 102° 7 o'clock P. M. Spasm of mouth has ceased ; respi- 
ration very slow and feeble ; pulse 80 ; temperature 102°. 10 o'clock 
p. M. Mucous rales heard over whole chest. 12 o'clock A. M. Patient 
remains unconscious. 2 o'clock P. M. Patient still breathes slowly and 
feebly ; small amount of frothy mucus comes out of her mouth ; patient 
remained in this condition until death, 10 A. M., 9th instant. 

Autopsy. — Head : dura mater normal ; sinuses empty ; moderate effu- 
sion into arachnoid cavity ; pia mater intensely congested ; left middle 
cerebral artery about J inch from its origin occupied by a firm thrombus ; 
beyond this the artery was thin, ribbon-like, scarcely perceptible, and 
finally lost ; membranes readily detached from the brain, leaving the sulci 
gaping widely over the under surface of anterior lobe, left side about third 
frontal convolution and island of Peil. In detaching the membranes por- 
tions of brain-substance were removed with them, leaving an almost pul- 
taceous mass exposed ; indeed the whole of under surface of anterior lobe 
was much softened, but this was most marked near the lateral border ; 
under surface of middle lobe slightly softened ; superior and lateral as- 
pect of anterior and middle lobes from fissure of Rolando forwards was in 
a very softened condition, breaking down under the least pressure, of a 
pale yellowish-gray color, in marked contrast with other parts of the brain, 
which on section showed very numerous puncta vasculosa, and were of the 
normal color. Thalamus opticus somewhat softer than that of the right 
side ; corpus striatum much softened and of a yellowish color. Thorax : 
lungs oedematous, and poured out an abundance of mucus on section. 
Heart : insufliciency of mitral valve ; no vegetations noticed ; left ven- 
tricle entirely filled by a firm white clot entangled in chordae tendinse and 
projecting into aorta; abdomen, kidneys, liver, and spleen much con- 



THROMBOSIS OF CEREBRAL ARTERIES. 149 

Causes. — Men are more often subject to arterial thrombosis than 
women or children, though we find the great number of cases of throm- 
bosis of the sinuses to be among women, and this perhaps due to the ten- 
dency of this sex to chlorosis. 

Gintrac considers very young children to be subject to venous throm- 
bosis. Of 37 cases seen by him, 14 were among infants ; but arterial 
thrombosis is a condition peculiar to advanced life, and instances before 
middle age are not at all common unless they be of a specific nature. 
The exciting causes are numerous, but it may be assumed in nearly 
every instance that the blood is in a state of hyperinosis as a consequence 
of acute disease, such as rheumatism or pneumonia. Excessive heat is 
very often a cause. Dickinson^ gives four cases, in two of which heat 
was the cause, in one other intemperance, and in the fourth violent 
vomiting, 

In many of these patients there is old heart disease with some enfeebled 
action of that organ. The basilar artery, which receives its blood from 
the vertebral arteries, may be the seat of a clot at its remote end when 
heart force is preternaturally weak, but this is a rare form of the disease. 
I have already spoken of peripheral phlegmatous troubles, and it is only 
necessary to call attention to the danger which may arise from carbuncle. 
The puerperal state favors the formation of thrombi, and just as phleg- 
masia alba dolens is brought about, so may the thrombosis of the cerebral 
arteries be produced. The graver variety of intracranial thrombosis may 
be produced by internal or external cause. Lancereaux collected 89 
cases, 30 of which were connected with caries of some of the cranial bones, 
and 24 with otitis. In one-half of these cases there were multiple ab- 
scesses of the brain. 

In conclusion I would allude to the possibility of traumatic origin, a 
variety of blood-states, and pressure from intracranial tumors, exostoses, 
and thickened meninges. 

Morbid Anatomy and. Pathology. — Von Dusch, Paraum,^ 
Grissole,^ Zahn, and a host of observers have devoted themselves to the 
study of this subject, and since the original observations of Kirkes* were 
published in 1852, which were devoted to the pathology of thrombosis 
as well as embolism, a great deal has been written. Parnum and 
Burro wes^ both experimented by iujectiug substances into the circula- 
tion, and Burro wes probably relates the earliest case of recognized throm- 
bosis. 

Zahn gives the following concise description of the pathological 
process which attends the production of the thrombus. " The intensity 
and the duration of the injury, together with the previous condition of 
the individual, determine the durability of the clot. The process of 

^ Loc. cit. 

2 Virchow's Archiv, xxv. 3—6, pp. 308—328, 433, 530, 1862. 

3 Pathol. Intern., p. 247. 

* Med. Chir. Trans, 1852. 
5 Med. Gaz., vol xvi. 1834-5. 



150 OCCLUSION OF INTRACRANIAL VESSELS. 

formation is the following. Colorless blood-corpuscles adhere to a part 
of the intima denuded by an injury of its endothelium. They accumulate 
there, form a ring-like obstruction, and gradually the clot obstructs the 
vessel altogether. If the injury be slight, and the nutrition of the indi- 
vidual unimpaired, the current of blood soon breaks through the blood- 
clot and carries along the flakes of the colorless blood-corpuscles. The 
normal condition is soon restored. If the injury of the vessel be more 
severe, and the surrounding tissue already in a state of irritation, the 
thrombus, whilst forming in the same way as described, is firmer and 
larger. The abstruction is more complete, and lasts for twenty-four 
hours and more ; after that period the thrombus begins to disintegrate 
into granular fibrine, the outlines of the blood-corpuscles composing the 
thrombus cease to be visible, and thus an uninterrupted circulation is re- 
established."^ In more serious trouble the detached clots may be the 
nuclei of larger ones in the sinuses if the condition of the arterial walls 
be such as to favor more extended formation of thrombi so that the 
vessels become entirely occluded. 

The consequence of arterial occlusion is the formation of an extended 
clot which blocks up the vessel more fully, and consequent ischsemia of 
distal parts. Through the agency of outside vessels collateral circulation 
is generally established in a short space of time. If, however, the ana- 
tomical site be such as to interfere with this provision of nature, softening 
or tardy degeneration will ensue. This softening, when it follows, is ex- 
pressed by a series of changes, which occur about as follows ; Red soften- 
ing in from 24 to 48 hours, while the yellow change does not take place 
until after 14 days. But of this condition of affairs I will speak in a sub- 
sequent chapter. The carotid arteries and their termination are more 
often affected, and basilar vertebrals, anterior cerebral, and posterior 
communicating come next, in the order that I have given them. The 
pathological processes in the second form, of intracranial thrombosis, viz., 
that affecting the sinuses and veins, are much more gross. Either 
through sluggish circulation of the blood on the part of a weak heart, 
pressure upon a sinus, or unusual density of the blood, coagulation^;oc- 
curs, the arterial flow is interfered with, a part of the brain is deprived 
of blood, and serum is effused. If the disease be due to outside causes, 
there may be an extension of inflammatory action from without in the 
manner I have described. By an extension of thrombosis, a form of 
meningitis resembling tubercular meningitis may be produced. Several 
of these cases have been seen by Scuch.^ An artery which is the seat of 
a thrombus presents these appearances : — The inner coat is rough and 
perhaps corrugated ; the artery as a whole may be hard and discolored, 
with diminution in calibre and a deposition of recent or ancient date, in 
which latter case it will be pale and tough, while atheroma is not un- 



1 Virchow's Archiv, Band Ixii., Heft 1, Nov., 1874. 

2 Verhandlung dur Wurz., p. Med. Geselschaft, viii. 179. 



THROMBOSIS OF SINUSES AND VEINS. 151 

commonly present. Fox^ has observed that the part of the plot ad- 
herent to the inner coat of the vessel is much more dense than that 
nearest the centre. When the capillaries are implicated, they are gener- 
ally found to be hard and calcareous. In thrombosis of the large sinuses 
or veins, the morbid appearances are much more striking. The thrombi 
are large, and, if old, of a gray color, and it is not rare to find pus- 
effusions of serum into neighboring parts, and perhaps some meningitis. 
Von Dusch has collected 57 cases, which are given by Fox.^ In 32 the 
thrombosis resulted from gangrenous, erysipelatous, and other inflamma- 
tions of the body (chiefly of head). In 15 it appears to have resulted 
from asthenic circulation. In 6 cases nothing positive could be ascer- 
tained. 

Diagnosis. — There are very few conditions with which that under 
consideration may be confounded. When we remember that in throm- 
bosis the development of symptoms is gradual, the loss of speech incom- 
plete, and primary ; and in cerebral hemorrhage the onset is sudden, the 
aphasia is secondary to a loss of consciousness, and the paralysis more 
marked, the diagnosis from this disease is not so difficult. Doubts may 
arise in our minds when we are to decide whether or not the case before 
us is one of thrombosis or uncomplicated softening. Thrombosis is rarely 
attended by marked elevation of temperature, while the opposite is to be 
observed in cerebritis, which presents as symptoms trembling and per- 
haps muscular rigidity. The psychical symptoms are also more strongly 
marked. The more serious form can be diagnosed by the coexistence of 
other conditions which may favor its origin. 

Treatment. — The chief indication seems to be : The improvement 
of the condition which influences the production of the thrombus. If 
arterial tension be at all weak, we may combine digitalis and iron, give 
tonics and improve the patient's general condition by good food and stimu- 
lants. Nature will arrange the process of collateral blood-supply, and 
we may aid her by enforcing rest and quiet. 



THEOMBOSIS OF SINUSES AND VEINS. 

When a large sinus or vein is involved, the resulting symptoms are 
much more complex and difficult to diagnose. 

Lancereaux,^ who has written quite extensively about this form of dis- 
ease, has divided into two grades, in regard to the variety of morbid 
action. One of these is inflammatory, the other is non-inflammatory. 
The first form is dependent upon the extension of some inflammatory pro- 
cess, usually from the ear, while the other is attended by coagulation of 
the blood in sluggish circulation. 



1 Path. Anat. of the JSTervous Centres, p. 32. 

2 Loc. cit., p. 35. 

3 De la Thrombose, etc, Paris, 1862. 



152 OCCLUSION OP INTRACRANIAL VESSELS. 

Yon Duscy does not agree with him, but Tonnele, quoted by Grisolle,^ 
makes the same varieties as Lancereaux. 

The seats of this pathological condition are the longitudinal, lateral, 
basal sinuses, and the large veins communicating therewith. Bastian^ 
alludes particularly to the longitudinal sinus as the most common seat 
and describes the tendency to plugging up of the cerebral veins on both sides. 

As I have said, the symptoms are very obscure, but in every case we 
may consider them to be the indication of pressure. Headache, delirium, 
coma, convulsions, ocular troubles, and generally death in a very short 
space of time mark the course of the disease. Mr. Tuckwell* reports a 
case which is a representative of the ansemic form. It is as follows : — 

Eliza C, set. 16, was admitted to Radcliffe Infirmary on the 20th day 
of April, 1871. She ceased working a month before on account of pal- 
pitations, shortness of breath, weakness, irregularity of the menses, etc. 
Two weeks before admission she began to suffer from violent headache. 
She never had fits. A condition of decided chlorosis was diagnosed. 
There was a systolic murmur at base and venous murmur in the neck ; 
nothing else abnormal was detected. She was put to bed. 

April 21. She sat up, but it was noticed that she lolled about in a 
strange manner, and seemed stupid. Her right hand and arm were weak, 
and she could not raise them to shake hands. Headache still severe. 

2ith. Kemained in same apathetic state; the paralysis of arm had in- 
creased, and she could not move fingers or hand at all ; headache. She 
became comatose, and died after the visit of Dr. Tuckwell and his col- 
league. Dr. Palmer. 

Autopsy twenty-four hours after death. On removing skullcap, the 
dura mater covering right hemisphere was found to be of a dark color, 
and the longitudinal sinus, when examined, was found half way blocked 
up by a firm white blood-clot of some age. Cerebral veins on the surface 
of the middle and posterior part of right hemisphere were all occluded 
by dark clots. On removing the brain, blood was found effused in the 
right middle cerebral fossa, extending down into the spinal canal. 

Lateral and basal sinuses were filled with clots of some age. The pons 
and medulla were covered by a clot of recent date. General softening of 
the brain was observable, the optic thai ami and corpora striata being par- 
ticularly affected. The arteries were all healthy, as well as the bone about 
the sinuses. 

Another case is reported by Dr. Tuckwell, which presented symptoms 
which were very much like those of his own case. 

Von Dusch^ has spoken of epistaxis with thrombosis of the longitudinal 
sinus as a common symptom, and Meissner has called attention to grind- 
ing of the teeth, profuse diarrhoea, and exhaustion, together with certain 
changes in the configuration of the head. In children he has found de- 

1 Zeits. fur Eation. Med. B. vii., 1859, p. 11. 

2 Op. cit., tome ii. p. 240. 

^ Paralysis frora Brain Disease, etc., p. 22. 

^ St. Bartholomew's Hospital Reports, vol. x., 1874, p. 35. 

5 Loc. cit. 



THEOMBOSIS OF SINUSES AND VEINS. 153 

pressed fontanellesj lapping of cranial bones, and unequal distension of 
the jugular veins. Metastatic abscesses, indicated by local symptoms, 
have been found by many observers. Lancereaux estimates that nearly 
half of all the cases are thus complicated. I have seen one case where 
erysipelas was undoubtedly the cause of the cerebral thrombosis, and 
after death the great sinuses were found to be filled with semi-purulent 
matter, and there were abscesses in the liver and other parts of the bod y. 
These cases are not so exceptional as they are generally supposed to be, 
but diagnosis before death is rarely made. 

An autopsy made at the New York Hospital by Dr. Amidon, who 
kindly invited me to be present, revealed the following beautiful evi- 
dences of thrombosis of the cerebral sinuses which followed septicaemia : 

The boy had died after several days' illness, the original injury being 
a compound fracture of the bones of the left leg. The autopsy was held 
on September 15th, the day of his death. 

The liver, kidneys, and lungs showed evidences of acute congestion, and 
the heart contained two ante-mortem clots ; one occupying the right auri- 
cle, and the other the right ventricle. The lungs were carefully exam- 
ined, and a pyramidal infarction was found at the border of the inferior 
lobe of the left lung. The head was opened, and the dura mater was found 
to be quite healthy, except in the superior longitudinal sinus, which was 
almost completely filled with a well- organized thrombus of a pale color. 
One of the large descending veins in the parietal region was occluded, 
and when the dura mater was removed, a large pouch, filled with limpid 
and perfectly clear serum, was found beneath, which pressed upon the pa- 
rietal convolutions just posterior to the fissure of Kolando. This was 
beneath the arachnoid. At no other point was there any abnormal col- 
lection of fluid, and in no place was there any evidence of structural 
changes of the brain-substance proper. The lateral sinuses were partially 
filled with thrombi, and contained some very fluid blood. The left pe- 
trosal vein was empty, as were others which were higher up. No arterial 
occlusion was found. The patient had died suddenly in convulsions 
with coma. 

Causes. — Blows upon the head, injuries of various kinds, extension 
of otitis, intemperance, and the causes I have already enumerated, 
may be mentioned. There seems to be no special dependence upon 
age or sex, though it may be said that most of the cases occur during 
adult life. 

What I have already said, and the excellent cases of Tuckwell, which 
have been presented, render it unnecessary to say more about the morbid 
anatomy, pathology or diagnosis. 

In regard to the prognosis, there can be no question. It is about as 
bad as it can well be. As to treatment, the most we can do is to build up 
our patient, and reduce the danger of external disease by favoring a free 
escape of pus if the original disease be otitis, and there be an accumula- 
tion. We may employ local cold and derivatives, but even these do little 
good after the disease is recognized. 



154 OCCLUSION OF INTEACRANIAL VESSELS. 



EMBOLISM OF THE CEREBEAL VESSELS. 

The cerebral arteries and capillaries are alike subject to this form of 
mechanical obstruction, but the former are perhaps the most common seat 
of the lodgment of fibrinous plugs. The little bodies which are forced 
into the vessels are always from some other part of the system, and are 
not formed in the vessel, as is the case in thrombosis. 

Embolism also differs from thrombosis in the fact that the latter is 
always developed, and attended by gradual narrowing of the vessel ; 
while the condition under consideration is a sudden accident, and may 
occur in a perfectly healthy vessel ; the converse is the rule in throm- 



Symptoms. — Unless there is previous acute endocarditis, there will 
seldom be any warning, the patient being suddenly stricken down as the 
little plug is violently forced into some vessel of the brain. There may 
even be no loss of consciousness, though this is the exception. Uncon- 
sciousness invariably occurs when a large embolon plugs up some such 
artery as the middle cerebral ; but if the embolon be small, and the ar- 
tery occluded is one concerned to a very limited extent in the vascular 
supply of the cerebrum, the unconsciousness may be but transitory, and 
psychical symptoms of slight moment will constitute the sole indications of 
confased mental activity. 

The eyes are sensitive to light, the pulse is small and rapid, and there 
is usually pallor. There are no indications of pressure, no stertor, no tu- 
multuous respiration, nor full pulse, and the pupils are either dilated or 
irregularly contracted. 

If the heart be auscultated, various murmurs or friction-sounds will in 
many cases be heard. Mitral murmurs are perhaps the most common. 

Paralysis taking the form of complete or incomplete hemiplegia is the 
result of such sudden arterial occlusion. 

Special facial muscles may be those affected, or various modifications of 
sensation, such as anaesthesia or hypersesthesia, may be detected, but rigid- 
ity or contractures are rarely present unless there is secondary disorgan- 
ization, and they are never seen during the early stages. Vertigo is a 
disagreeable and common symptom, and is sometimes attended by cere- 
bral vomiting. Of course aphasia is an almost invariable consequence of 
embolism, as the middle cerebral artery is so commonly occluded. This 
aphasia is of variable extent, and is ataxic or amnesic, but generally the 
latter. On the other hand, the patient may be simply stupid and taciturn, 
refusing to answer, or he may be troubled with a light form of clumsi- 
ness or slowness of speech. The headache, which is subsequent to the loss 
of consciousness, is coincident ordinarily with the re-establishment of col- 
lateral circulation, and if further changes occur there may be intense 
head-pain, delirium, mania, or symptoms indicative of softening. The 
duration of this stage varies greatly. I have seen examples where the 
symptoms were trifling and transitory, such as headache, awkward 



EMBOLISM OF CEREBRAL VESSELS. 155 

speech, and paralysis of one arm rapidly disappearing. Other cases are 
correspondingly serious. Mr. Shaw^ reports a case which proved fatal in 
twenty-four hours, and others have detailed examples in which death en- 
sued in from thirty-six to forty-eight hours. 

It is very common to find, at the same time, symptoms indicative of 
embolism of other organs. The spleen, lungs, and organs which receive 
a large supply of blood, or are in the direct line of arterial supply, are apt 
to be involved as well as the brain. It rarely happens that two or more 
cerebral arteries are simultaneously plugged. In such cases the symptoms 
are complicated. One case is recorded in which both middle cerebral 
arteries were occluded, and the following case reported by Sokolowski^ is 
an example of coexisting splenic and cerebral embolism : — 

The patient was a servant, married, aged 23, who had always menstru- 
ated regularly, except when she was pregnant second year before, and 
then gave birth to a healthy child. Her health had been ordinarily good. 
Four days before her admittance to the hospital she had suffered from 
alternate chills and heat, with headache and constipation. On admis- 
sion her pulse was 100 ; temperature, 102.6°. Heart friction sound 
at apex, but nowhere else. Passed 53 oz. urine in 24 hours ; sp. gr. 
1025. 

October IZih. She suddenly became paralyzed on the right side, lost all 
power of speech, and only moaned and cried in a frightened manner. The 
third day after, acute idiopathic endocarditis was diagnosed. The right 
ventricle was found to be greatly enlarged. Temp. 101.2° ; pulse 100. 
After paralysis she lost hearing in the right ear ; pupils were normal ; left 
side of mouth was drawn up. Anseesthesia of paralyzed parts. Urine and 
feces passed unconsciously. Spleen tender and enlarged. An additional 
diagnosis was now made. Embolism of left middle cerebral artery, and 
embolism of splenic artery. The loss of speech was peculiar. She was 
unable to articulate at all, though there was sufficient evidence of mental 
activity and originating power, so she communicated with her friends by 
signs. The paralysis had begun to disappear in the right leg below the 
knee, and she could move her foot slightly. The temperature on the first 
day was 102.2° ; pulse 90. In the evening, 104.8° ; pulse 100. On the 
second day, Oct. 14, there was much improvement. The morning tem- 
perature was 102.8°, and the evening 103.8°. 

Ibth. All paralysis and alalia have vanished. She is, however, ex- 
tremely weak. During the next two or three days a diarrhoea, loss of 
appetite, and considerable increase of tenderness over the spleen appeared. 

2^th. 35 oz. of urine were passed, which contained albumen, hyaline 
casts, and urates in abundance. 

November 10th. She has grown gradually worse, is no longer able to 
answer questions, but repeats words and sentences over and over. There 
is marked loss of memory. The fever has greatly increased, the evening 
temperature being 105.2° ; pulse 120, and quite thready. There are evi- 
dences of bronchitis and pulmonary difficulty. Urine greatly decreased 
in quantity, and albumen increased ; tongue quite dry. 

^ Trans, of Path. Soc. of London, vol. iv. 
2 Deutsche Med. Woch., Dec. 15, 1875. 



156 OCCLUSION OF INTRACRANIAL VESSELS. 

20th. She died. There was extensive hypostatic pneumonia ; conscious- 
ness remained to end. 

Autopsy. — Arteries at base healthy, except middle cerebral on left side. 
This contained a semi-transparent embolism of cartilaginous consistency. 
Right side of brain healthy, though pale. The left side in the same con- 
dition, except at the island of Reil, and gray matter of lenticular nucleus, 
which were small, hard, and yellow, and showed evidences of softening 
and subsequent cicatrization. The heart was enlarged, and yellow spots 
were found beneath the endocardium. The edges of the mitral valves 
were thickened and covered with coagula. The spleen enlarged, " blocked," 
and the splenic artery occluded. 

Cases have been reported where embolism followed, or was connected 
with, chorea, and this connection has been made use of in the explanation 
of the pathology of the latter disease. One of these cases, seen by Murchi- 
son,^ is worthy of mention. 

The patient, a boy 14 years old, had suffered from chorea when seven 
years old, from which he recovered. Two weeks before he died, irregular 
choreic movements appeared, connected with a bellows murmur at the 
left apex. When seen, June 12th, the pulse was 120; temperature 102°. 
There was a pericardial friction sound, but no pain in joints or other 
symptoms of rheumatism or endocarditis. 

June 28. Sudden unconsciousness, head drawn to right side, extreme 
rigidity, twitching on right side. Pulse 145. Pupils normal and equal, 
but subsequently contracted ; no paralysis. Died June 29. Vegetations 
on mitral valves, spleen containing emboli. Left vertebral and left in- 
ternal carotid arteries blocked by pale, firm, and easily detached coagula ; 
left hemisphere considerably softened. Examination revealed no small 
emboli in capillaries. 

A case of my own, showing an accident which may occur in the course 
of certain acute diseases, seems to me to be of sufficient interest to present, 
as it may call attention to a cause of death which is probably sometimes 
overlooked. 

Mr. !N., set. 35, a stout, full-blooded man of good habits and no vices, 
took to his bed on the 25th of June, 1874. 

He had contracted a " bad cold " at the theatre, and the next day was 
seized with pain in the left side, was chilly and uncomfortable, and when 
I saw him on the evening of the same day, he had a violent headache. 
His skin was hot, and his pulse hard and rapid. The thermometer indi- 
cated a temperature of 101° ; pulse 122. At the base of the left lung 
crepitant rales were heard. Flaxseed poultices were applied, and quinine 
and other remedies administered. For the next four or five days the 
lungs underwent consolidation, and nearly all of the physical signs con- 
nected with the different stages of pneumonia were observed. The most 
marked of these was a high temperature, which ranged between 103° and 
105° for six days. Resolution was slow, and but a few sputa were brought 
up, but the temperature had fallen to some extent. I was sent for in haste 
on the evening of the fourteenth day, an hour after my ordinary visit, to 

1 London Path. Soc. Trans., vol. xxii. 



EMBOLISM OF THE CEREBRAL VESSELS. 157 

find that the patient had suddenly, while taking his beef-tea, fallen back 
unconscious, and had remained so ever since. This was about half an 
hour before my being sent for. 

His pupils were widely dilated, and his cornese when touched were sen- 
sitive ; his legs and arms were extended. His temperature was not high, 
and his breathing had not changed very much from what it was when I 
saw him earlier in the day. 

After an hour and a half he made some movements which showed 
slight voluntary control, and vomited, turning his head slightly to do so. 
He uttered no sounds except low moans. Towards morning his breath- 
ing became more troubled, and he rolled in the bed. 

At about nine o'clock in the morning of the next day he seemed to 
recognize those about him, and made signs which were not understood, 
when he knit his brows and seemed perplexed. He refused food, but 
permitted an enema of beef-tea to be injected, but this was not retained. 
It was then found that he was hemiplegic on the right side. Later in the 
day he passed his urine in bed. 

l(^th day. Did not sleep last night. The temperature 104° ; pulse, 
130, full and hard. After my visit this morning he became comatose. 
3 p. M., died. 

Autopsy 20 hours after death, — Lungs: right, rather more pinkish 
than normal ; some spots of induration at base. Left, solidified through- 
out most of its substance ; when cut, bloody serum exuded. Heart some- 
what enlarged. Mitral valves were covered by stringy clots. The right 
ventricle contained a large fresh clot. Kidneys : right, normal ; left, 
somewhat smaller than it should be ; contained a small cyst beneath the 
capsule. Head : On opening the cranial cavity, the vessels of the dura 
mater were filled with dark blood. The longitudinal sinus contained a 
quantity of thick, clotted blood, which was almost black. The left hemi- 
sphere was cedematous, except at a point beneath the lateral ventricle, 
where there was a circumscribed patch of a pinkish hue, which seemed to 
be well defined. The left middle cerebral artery, at a point just before it 
gives ofi* its branches, was found to be swollen and hard, and when cut 
open a small, rather firm clot was found. Behind this there was a long, 
stringy clot of more recent date. About the vessel the brain was cedema- 
tous. Another patch of red softening was Ibund in the same hemi- 
sphere somewhat more posteriorly. No other large arteries were 
afiected, but when microscopically examined, I found considerable occlu- 
sion of many small capillaries, and great disorganization of the nerve 
element. 

I have seen several other cases of this kind occurring during acute dis- 
eases attended by a hyperinosed condition of the blood. 

Causes.— Endocarditis is, above all other causes combined, the most 
important and common in the production of embolism. At the Patholo- 
gical Institute of Berlin^ there were 300 cases of embolism of all kinds 
associated with endocarditis during the years included in the period be- 
ginning 1868, and ending 1871. Twenty per cent, of these cases were 
of brain embolism. Of a large number of cases reported in the London 
Pathological Society's Transactions, nearly all of them were of this 

1 Edinburgh Med. Journ., July, 1873. 



158 OCCLUSION OF INTRACRANIAL VESSELS. 

nature ; and out of fifteen cases I have seen, twelve were connected 
with disease of the heart, and generally with deposits upon the mitral 
valves. 

Croup, the puerperal state, phlebitis, and other conditions where there 
is any tendency to the formation of clots, or the detachment of tissue 
which finds its way into the circulating apparatus, may all produce em- 
bolism. 

Numerous accidents which happen through carelessness, or perhaps 
unavoidable injury during surgical manipulation, may, by the introduc- 
tion of a blood-clot or foreign substance into the circulation, produce an 
occlusion of some cerebral or other vessel. This accident has occurred 
when pressure has been made upon large aneurisms, and is one of the 
arguments against the intravenous injection of substances which coagulate 
the blood, such as ergot, persulphate of iron, hair, or other organic sub- 
stances. 

Dr. Barker^ has given two cases of embolism following the parturient 
state, and Thomas has seen one or more cases of this kind. 

As to age, I have found that more young people have had cerebral 
embolism than persons of advanced life. An examination of twelve 
cases reported by difierent observers gives the relative frequency as fol- 
lows : — 



tween 10 and 20 years . 


2 


Between 40 and 50 years . 


2 


" 20 " 30 " . 


4 


" 50 " 60 " . 


1 


30 " 40 " . 


3 







Of these, 3 were males, and 9 were females. 

Of my own cases, seven were between twenty and thirty ; five between 
thirty and forty ; and three between forty and sixty. Eight were women, 
and the others men. It seems, therefore, that the period between the 
twentieth and thirtieth years is that in which the disease is most common, 
and that women are most subject to the disease. According to the ob- 
servations of medical writers in general, mitral disease is more often an 
afiection of youth or early life than of advanced years ; so it seems pro- 
bable that people who have not reached middle life should be more sub- 
ject to embolism. 

Diagnosis. — The important distinction is to be made when we sus- 
pect the case to be one of cerebral hemorrhage. Next in order come 
thrombosis, cerebral congestion, meningeal hemorrhage, and cerebral 
tumor. 

Gelpke^ has given the following table, on one side of which are detailed 
the features of cerebral embolism ; on the other, those of cerebral hemor- 
rhage : — 

CEREBRAL EMBOLISM. CEREBRAL HEMORRHAGE. 

Youth of patient. Advanced age, atheroma. 

Sudden onset without prodromata. Prodromata generally present. 

^ Puerperal Diseases, p. 270. 

2 Archiv der Heilkunde, xvi., Aug. 1875, p. 485. 



EMBOLISM OF THE CEREBRAL VESSELS. 159 

Previous articular rheumatism, val- Hypertrophy of left ventricle, 

vular sounds. 

Previous disease, which might lead 
to formation of clots. 

The Attach. The Attach. 

Extensive muscular paralysis ; amne- Symptoms of cerebral pressure ; ataxic 

sic aphasia. aphasia ; involvement of the intelligence. 

Very rapid ; or quite imperceptible Disappearance of the residual dis- 

disappearance of the residual disorder. order after a moderate time. 

Ketention of early mental power. Eeaction stage. 

Janeway^ relates an admirable case to illustrate the obstacles some- 
times encountered in making a diagnosis. As it will be seen in his case, 
there were many circumstances of a puzzling character which made the 
diagnosis exceedingly difficult. 

A young woman, while at work, fell to the floor unconscious, in what 
appeared to be a " fainting fit." There were some convulsive movements 
limited to the left side of the body. When admitted to Bellevue Hos- 
pital on the following day, there were irregular contraction of the pupils, 
coma, and high temperature. A loud systolic murmur was heard all over 
the chest. She remained unconscious for two days, and on the third 
day died. Her breathing previous to death was stertorous, her limbs 
flaccid, and reflex action diminished. The pupils were dilated. Her 
urine contained a small amount of albumen, but not enough, in the ab- 
sence of oedema and other symptoms, to suggest nephritic trouble ; be- 
sides, the quantity of urine passed was sufficient. The question of throm- 
bosis was excluded by the absence of premonitory symptoms. Congestive 
chill was suggested by the paralysis and meningeal hemorrhage, but ex- 
cluded when the absence of rigidity was taken into account, janeway 
considered the lesion to be hemorrhage, and I will give his own descrip- 
tion of the autopsy and its result. 

^'T\iQ post-mortem examination revealed the following: Skull, normal. 
Brain and membranes : On opening the dura mater on the right side, 
a clot of blood, a little over half an inch thick, three inches long, and 
two inches wide, escaped from the arachnoid sac. This clot was in the 
main, black, moderately soft, but provided with a bufiy coat at one por- 
tion. It had produced a corresponding depression of the brain, over 
which it was situated, and in its centre was an opening about an inch 
long and a half inch wide, leading from a recent excavation in the middle 
lobe of the brain, through the torn pia mater and so-called arachnoid, into 
the sac of the latter. This excavation reached from the convex surface 
nearly to the corpus and optic thalamus at posterior extremity. The 
opening was situated a little nearer to the longitudinal fissure than would 
correspond to the middle of the convex surface. The excavation was 
about two inches wide and contained clotted blood, of which some had 
escaped in removing brain. The brain- tissue surrounding this was soft, 
slightly blood-stained, and where it formed the boundaries of the space, 

^ Am. Psychological Journal, Nov. 1876. 



160 OCCLUSION OF INTRACRANIAL VESSELS. 

numerous small torn vessels. The brain-tissue of the posterior lobe, espe- 
cially on its outer surface, was softer than natural. The posterior ex- 
tremity of the optic thalamus of the right side, over a small area, pre- 
sented an ecchymotic softened state. 

" In the clotted blood and disintegrated brain-tissue found at the mouth 
of the excavation, a small branch of the posterior cerebral was found torn 
across, presenting a widened extremity at the point^of rupture, surrounded 
by thickened and firm tissue, and in the interior of this a firm reddish- 
gray clot, uniform in its structure and of older date than any others. I 
failed on careful examination to find the other extremity of the torn ves- 
sel, but from the condition of the portion found doubt not that it would 
have proved of similar shape to the other, and that together they would 
have constituted a cylindrical dilatation of this artery. 

" The left (opposite) hemisphere showed the convolutions flattened and so 
closely pressed together laterally as to nearly obliterate the appearance 
of sulci. The arach noid was dry, and there was no sub-arachnoid fluid 
present. The brain on this side appeared anaemic, and on cutting the 
dura mater, pressed out. 

" The lateral ventricles were of normal appearance. The anterior lobe 
of right side was normal. Pons, cerebellum, etc., were normal. The 
arteries at the base were carefully examined, being followed to their 
smaller ramifications without finding any emboli. 

" The lungs were slightly oedematous. 

" Heart : The left ventricle was slightly hypertrophied. On the auri- 
cular aspect of the mitral valve, and on the ventricular of the aortic, 
condylomatous excrescences were present, narrowing both orifices ; but 
the largest mass passed obliquely across the heart from the leaf of aortic 
valves nearest the septum to the anterior leaf of mitral valves, and above 
this, between it and the other leaflet of aortic valves, a slight dilatation 
of the heart-wall existed. 

" Small infarctions were present in the spleen and the kidney, and the 
latter showed at some points interstitial nephritis, around glomeruli, with 
atrophy of these ; but the disease was not advanced. The mesentery pre- 
sented two small aneurismal dilatations of little arteries, and at these 
points emboli were present : one was of the size of the head of a pin ; the 
other, of a pea. 

" In this case it seems exceedingly probable that the primary lesion of 
the artery, which finally ruptured, was embolism, and that this obstruction 
caused, secondarily, a dilatation of the artery at this point, and that, 
owing to the heat,^ such an obstruction of the circulation in the brain oc- 
curred as to cause the rupture of the vessel described. This is rendered 
still more probable by finding two small arteries in the mesentery with 
aneurismal dilatation, and containing emboli. 

"A point of interest in this case is the absence of serious symptoms of 
cardiac disease, though there was so marked a lesion. It did not seem 
as if aay regurgitation had occurred at the aortic orifice, simply obstruc- 
tion. The left ventricle contained such a firmly adherent clot that the 
hydrostatic test was of no avail. 

^ The weather was excessively warm at this time, and the patient was at first sup- 
posed by those around her to be sufiering from the effects of the heat. 



EMBOLISM OF THE CEREBRAL VESSELS. 161 

" It also furnislies another to the already long list of cases in which a 
heart-murmur is heard — sudden paralysis occurs — the patient moderately 
young, and yet the lesion is hemorrhage, and not embolism. I have met 
with several of these exceptions." 

From thrombosis there will be no difficulty in making a diagnosis when 
we remember the slow origin of the former. The " apoplectic form " of 
cerebral congestion sometimes resembles the condition presented by the 
patient ; however, the former history, the suffused face, contracted pupils, 
and rapid subsidence of symptoms, will put us on our guard. 

Morbid Anatomy and Pathology.^-Burrowes and Kirkes were 
the first Euglish writers and Virchow the earliest Continental writer to 
describe these conditions. Pre vest and Cotard have since related inter- 
esting experiments. They injected tobacco seed into the carotids of dogs, 
and afterwards watched the changes that followed. One of these dogs 
was killed thirty-nine days after the seed had been introduced, when they 
found the middle cerebral artery obstructed, and induration about the 
fissure of Sylvius. 

The pathological processes which follow such mechanical obstruction 
have been sufficiently noticed in a preceding article, so it will be enough 
to call attention to the fact that the consequence of such an accident will 
be softening of the parts deprived of their nourishment, unless the collat- 
eral circulation be established at an early date, or the embolon is broken 
down and removed, which is a very unlikely circumstance. 

Kirkes ^ calls attention to the distribution of emboli in the following 
words : " The parts of the vascular system, within which these transmit- 
ted masses of fibrine may be found, will of course depend in a great 
measure upon whether they proceed from the right or left side of the 
heart. Then, if they have been detached from either the aortic or mitral 
valves, they will pass into the blood propelled by the left ventricle into 
the aorta and its subdivisions, and may be arrested in any of the systemic 
arteries or their modifications in the various organs, especially those which, 
like the brain, spleen, and kidneys, receive large supplies of blood di- 
rectly from the left side of the heart. If, on the other hand, the fibrinous 
masses are derived from the pulmonary artery and its subdivisions within, 
the lungs will necessarily become the primary if not the exclusive seat of 
their subsequent deposition." 

In regard to the side of the brain where the deposit occurs, I think we 
may, say that the left side and the middle cerebral artery are the most 
common site, though many cases reported by Shaw, Glynne, Murchison, 
and others prove that the right artery may be affected as well. 

An interesting example, which is almost unique, is the following case of 
embolism of the right posterior cerebral artery. The history was read by 
Broadbent before the London Clinical Society : — ^ 

" The patient, a young man aged 19, had suffered three years pre- 

^ Eoyal Med. Chir. Trans., vol. xxxv., p. 281, 1852. 
^Abstracted from Lancet, Monthly Abstract, April, 1876, p. 576. 
11 



162 OCCLUSION OF INTRACRANIAL VESSELS. 

viously from acute rheumatism. Ten days before his admission, he sud- 
denly became blind, and had great pain in the head. Five days later, 
vision having returned, he lost the use of his left limbs, while the right 
arm and leg were continually in motion ; and, unless restrained, he rolled 
over and over towards the left, falling out of bed and bruising himself se- 
verely. The left hemiplegia and uncontrollable movements of the right 
limbs continued when he was admitted ; the hemiplegia not being abso- 
lute, but accompanied by slight rigidity and very considerable impair- 
ment of sensation. The patient took no notice of persons or objects, but 
answered questions, and put out the tongue on being urged. His pulse 
was variable, 120 to 160 or more. Temperature in the right axilla, 
99.2°; in the left, 100.6°. A loud mitral systolic murmur was present. 
The bowels were confined, and, when opened, the feces and urine were 
passed in bed. A dose of three grains of calomel was given, and two 
grains of carbonate of ammonia, with two drachms of infusion of digitalis 
every two hours. Chloral also was given at night. He was ordered a 
diet of milk and beef-tea, with four ounces of brandy. There was gra- 
dual improvement ; and three days after his admission, an ophthalmosco- 
pic observation, previously attempted in vain, was obtained, and the disks 
were found to present the appearances of marked ischsemia. The pulse 
was now 108, soft, short, and strikingly dicrotous. A day later the pulse 
was 88, and more full. The temperature was still nearly a degree higher 
in the left (100°) than in the right (92.2°) axilla. Slight paralysis of 
the left external rectus of the eye was observed. At the end of a fort- 
night's stay in hospital, the right limbs were quiet, and there was 
considerable return of power and sensation in. the left side. His speech 
was rath'T slow, but there was no obvious impairment of the intellect. 
Notwithstanding this, however, he not only passed his feces in bed, but 
threw them about and bedaubed himself and the bedclothes without any 
regard to decency. The optic ischsemia was marked, but vision was good. 
The temperature of the right axilla was 99.3°; of the left, 100°. At the 
end of three weeks he passed his excretions naturally. After five weeks 
lie was up and about, eating well ; but pale, and still complaining a little 
of headache. Impairment of power and of sensation in the left limbs 
was still perceptible. The optic neuritis was subsiding. Distant vision 
was good, but small print was not easily read. A systolic mitral mumur 
was heard. The temperature was still never below 99°; usually 100° ; it 
was now equal on the two sides. But for this elevation of temperature, 
the patient would have been allowed to leave the hospital. Soon after- 
wards, however, there were symptoms of splenic embolism, and later of 
ulcerative endocarditis; and he died from this four months after admis- 
sion. On post-mortem examination, with ulcerative endocarditis and nu- 
merous recent embolisms, there was found softening of the occipital lobe 
of the right hemisphere from the posterior cornu of the ventricle down- 
wards, and the branch of the post-cerebral artery entering the calcarine 
fissure was occluded and lost in adhesions. It was considered probable 
by Dr. Broadbent that originally the posterior cerebral artery itself had 
been blocked up, and not only this branch. The interesting points in the 
case, on which comments were made, were the temporary blindness, the 
agitation of the right limbs, and rolling tendency, the usual association of 
loss of sensation, and of double optic ischsemia with embolism of a cere- 
bral artery, and the remarkable indiiference to decency persisting when 
the intellect was apparently good." 



EMBOLISM OF THE CEREBRAL VESSELS. 163 

Fat globules may sometimes plug up the small capillaries, producing 
wide areas of softening. 

The morbid appearances indicative of cerebral softening are of interest 
and worthy of the closest study, not only because the brain is the point 
which suffers the most seriously, but because generally the heart, spleen, 
lungs, blood-vessels, and other organs may be involved as well. On the 
valves of the heart, either mitral or aortic, may be found excrescences, 
induration or recent clots, and the arteries themselves may exhibit patches 
of atheroma. In th^ brain we will probably find one or more of the ar- 
teries I have spoken of to be swollen, hard, and filled by one of these 
little masses of fibrine. They have been compared to grains of wheat, 
and resemble them very closely. Generally the embolon is separated 
from a second plug which has followed clotting of the arrested blood. 
Emboli are never attached to the walls of the vessels. 

Several arteries may, perhaps, be found obstructed in the same way. 
" Sometimes all on one side ; at other times some arteries of one side of 
the brain, and some of the other,"^ so says Fox. 

Softened masses are generally found on examination, and are usually 
the cause of death. The parts behind the occlusion are subjected to the 
full force of blood which is arrested, and not sent to the parts it should 
supply, and local hyperaemia is a result. The resulting softening is 
generally confined to the left hemisphere at its base, for reasons 
I have before stated, and the frontal convolutions, corpus striatum, 
and adjacent parts are found to be either red or yellow, softened or in- 
durated 

(Edema of the brain is not an uncommon appearance, such oedema 
being seen in the parts deprived of blood. The perivascular spaces being 
enlarged, it is but natural that their fluid should rush in to fill up the in- 
creased space left by the bloodless arteries. 

Prognosis. — The outlook for the patient is generally a very gloomy 
one if the accident be at all grave, and the artery be one of importance. 
The severity of the symptoms, the existence of emboli in other organs, 
the element of severe pain, high temperature, and gradual development 
of symptoms indicative of softening are of unfavorable import, and give 
affairs a very dark look ; therefore it is never well to make too hasty a 
prognosis. 

Treatment. — Eest, abstinence from stimulants, and agents which 
will diminish the arterial tension are the only remedial means to adopt 
besides the ordinary indications which appeal to the common sense and 
discretion of the medical man. Afterwards, resulting conditions, such as 
paralysis or softening, are to be treated. 

1 Op. cit., p. 32. 



164 DISEASES OF THE CEREBRUM AND CEREBELLUM. 



CHAPTEE V. 

DISEASES OF THE CEREBRUM and CEREBELLUM (Continued). 
CEREBRAL SOFTENING. 

Synonyms. — Remollissement (rouge, blanc, jaune). Encephalitis 
aigae, chronique (Fr ). Mollities cerebri, Encephalitis, Softening of the 
Brain (chronic, acute), Inflammation of the Brain. 

Definition. — A disease of the brain attended by destruction of ner- 
vous substance, and either of an acute inflammatory nature, with puru- 
lent formation ; or of a chronic non-inflammatory character, with less 
rapid disorganization of nerve-tissue. 

So much confusion has arisen from an incorrect appreciation of the 
morbid anatomy and its connection with pathology, that it is a difiicult 
matter to attempt there conciliation of the many widely diflfering views 
of the legion of writers " Inflammation of the brain " is the term which 
has led to all this confusion ; and I have been bold enough to base my 
classification rather upon the character of tissue-changes than upon the 
arbitrary law that softening of the brain is the only result of in- 
flammation. Sclerosis, as we know, is undoubtedly the result of a low 
grade of inflammation, but in this case the tissue-changes are quite 
different. 

Considering that the word " softening" means a mollification, and that 
it may result not only from purulent inflammation, but from low nutritive 
changes, I shall divide the subject as follows : — 

w A , o ^^ . r Diffused Cerebritis. 

1. Acute Softening, \ ,, . ^ , . . 

< Memngo-Cerebntis. 
(Inflammatory), ( Purulent Cerebritis. 

2. Chronic Softening,. f Primary Softening. 
(Non-Inflammatory), 1 Secondary Softening. 

1. Under the first head we may place the variety described by Elam,^ 
which is a quite rare aflPection in its uncomplicated form, that is, when it 
involves the brain substance en masse; and meningo- cerebritis, which is 
by far more common. In a third variety the acute disease is character- 
ized by purulent collections, and perhaps by the ultimate formation of 



2. Chronic softening in its primary form we will consider to be de- 
pendent upon general disease, intellectual prostration, and like causes ; 

^ Cerebria, and other Diseases of the Brain, London, 1872. 



ACUTE SOFTENING. 165 

while " secondary softening " may be used to express the form which 
follows vascular lesions, such as embolism, thrombosis, or cerebral hemor- 
rhage. 

ACUTE SOFTENING. 

In the first form it may be either cortical, diffused, or combined with 
meningitis. 

Symptoms. — Cerebritis of either kind is preceded in nearly every 
instance by symptoms of functional disorder, such as cerebral congestion 
or cerebral ansemia, but these are not sufficient in themselves to arouse the 
suspicion of the observer as to the serious character of the disease which 
is to follow. The later prodromata of cerebritis, however, cannot be mis- 
taken, and finally the developed disease presents most pronounced symp- 
toms, which, if they do not always enable us to locate the brain lesion, are 
sufficient to assure us that some violent inflammatory process is under 
way in the cerebral mass. The patient may for some months suffer 
greatly from headache of a diffused character, accompanied by burning 
sensations, and a sense of pressure behind the eyeballs. These headaches 
are quite intense, and are aggravated by exposure to heat, concentration 
of the mental powers, and alcoholic indulgence. His memory becomes 
gradually enfeebled, so that at first dates and names are forgotten, and 
afterwards faces, locations, and even information which may have been 
imparted to him a short time previously.. Some slight clum-iness of 
speech may be indicative of the near approach of grave symptoms, but 
this clumsiness is not aphasic till later. Irritability of temper, restless- 
ness, and incapacity for mental application are attendant evidences of the 
smouldering fire which afterwards is to make itself known by still more 
decided symptoms. Among these may be enumerated nystagmus, stra- 
bismus, diplopia, and optic neuritis, as ocular troubles ; contractures of 
the limbs, tremors of individual muscles, or groups of muscles, a twitching 
of the limbs, or other motor troubles, and hypersesthesia, followed by anaes- 
thesia, and other disorders of sensation ; these last sometimes being pe- 
culiarly prominent. Next we find that there may be an apoplectic 
attack or convulsions of an epileptiform character, which mark the violent 
stages of the disease. Should there be, as a result of the morbid process, 
cerebral hemorrhage, it Avill be found that the paralyzed limbs become 
markedly contracted, and that rigidity is a striking feature, as the result 
of descending degeneration. According to Jaccoud, the contractures may 
be bilateral, though the rule is the other way, the limbs of but one side 
being rigidly flexed.^ He has seen one case where the left arm and leg 
were the seat of contractures, and where the face was contracted and 
strongly drawn towards the left side, suggesting a right facial palsy, but 
the appreciable rigidity of the facial muscles of the left side left no doubt 
as to the origin of the deviation. The paralyzed members are generally 

1 Traite de Path. Interne, vol. i., Art. Enceph. aigue. 



166 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

those that are the seat of convulsive movements in the first place. The 
convulsions may be general, and assume an epileptiform character, and 
may be accompanied by vomiting. The patient's, mental condition mean- 
while undergoes a great change. Delusions, which somewhat resemble 
those of general paralysis of the insane, are present ; the exaltation deli- 
rante of the French, which is by some considered to be an early symp- 
tom. This has not been my experience, and I am convinced that in the 
cases where it has been noticed as an early expression of the affection, the 
disease was probably general paralysis, and not cerebritis. The real de- 
partures from mental integrity are expressed in a want of decision and a 
restlessness which is shown in the impaired fixedness of purpose. The pa- 
tient repeats himself in conversation, and forgets that he has made the 
same statement but a few minutes previously. Memory is ultimately 
abolished, and finally dementia remains, which, should the patient live for 
some time, is expressed by all the other signs, drivelling of saliva, inane 
smile, hebetude, and total imbecility, while there may be aphasia of the 
amnesic or ataxic variety. The muscles concerned in articulation and 
deglutition are involved, and the patient may narrowly escape being 
choked by the masses of food which " go down the wrong way" or accumu- 
late in his mouth. Constipation and retention of urine are not uncom- 
mon accompaniments, and the urine is charged with urates, is dark-colored, 
and rapidly undergoes decomposition. The temperature and pulse are 
both changed, the latter becoming accelerated and irregular, and the heart- 
sounds sharp and " precipitative." A tremulous character of the pulse 
has been noticed by several observers. The temperature may rise to 110° 
F., and generally attains its highest point at the end of the first four days. 
Coma precedes a fatal ending in the acute form at the end of a few days, 
and death occurs generally after seven or eight days by asphyxia. Should 
the patient survive, there is a remission of the symptoms, and the forma- 
tion generally of an abscess. Cerebritis does not always begin in the same 
way, and, as I have already stated, is not invariably symptomatized by all 
the forms of disordered function I have enumerated. There may be no 
premonitory symptoms should the disease follow otitis or injury, but in 
the insidious form, which has been so admirably described by Elam and 
Reynolds, the appearance of prodromata is gradual and progressive. In 
certain cases the paralysis is an early symptom, in others the defects of 
articulation and deglutition are more prominent ; in other cases psychical 
disturbances are decided, while in still others coma or convulsions are the 
striking features. The predominance of these different symptoms depends 
very much upon the region which suffers the most from the violence of 
inflammatory action. It must be borne in mind that the disorder is, as a 
rule, attended from the first by febrile disturbances, and that all the symp- 
■ toms are those indicative of a hypersesthetic state of the cerebrum. 
Should the patient survive the immediate violence of the attack, he may 
recover to some degree. The temperature and pulse are lowered ; the ac- 
tive evidence of the central disease subsides, but it is not common for any 
amelioration of the paralysis to take place. The headache may become 



ACUTE SOFTENING. 167 

more localized and less intense, or may subside altogether, and it may 
only reappear when the patient is fatigued. He may remain in this con- 
dition for several years. In one case that came under my observation I 
accidentally found a large abscess about the size of a horse chestnut in the 
white matter of the anterior lobe of the right hemisphere. The individual 
had died of phthisis, and during life complained of no symptoms which 
would direct suspicion to the brain lesion. He had had a febrile attack 
six years before, which was probably the time at which the abscess was 
formed. In many cases cerebral abscess follows disease of the temporal 
bone, and in the majority of instances it is not essentially necessary that 
there should be complicating general meningitis, though such is often the 
case. 

Causes. — Exposure to the sun's rays, alcoholism, inflammatory dis- 
ease of the bones of the head or face, meningitis, brain tumors, trauma- 
tism, and syphilis, as well as several of the zymotic fevers and rheuma- 
tism, are all predisposing and exciting causes of cerebritis. The simple 
form may be idiopathic, but that which results in the production of 
abscesses is more often due to traumatism, caries of adjacent bones, or 
syphilis. Jaccoud has found that the proportion of patients in regard to 
sex was in favor of the males, nine men being affected to every four 
women, and that the disease was developed between puberty and the forty - 
fifth year. Cerebral abscess or traumatic cerebritis may be produced, of 
course, at any age by injuries or the extension of other diseases. I have 
seen one case in which cerebritis followed otitis in a child ten years old. 
Lead poisoning should not be forgotten as a rare cause. 

Morbid Anatomy and Pathology. — Cerebritis may either in- 
volve the cortex cerebri or some central parts, such as the corpora striata 
or optic thalami, or more rarely may affect the entire brain, but it pre- 
fers the gray matter, which is so richly supplied by blood vessels. The 
brain may be found to be the seat of many softened parts, and collections 
of pus, serous exudation from the vessels infiltrating the surrounding 
brain-tissue, or there may be ruptured vessels, and an escape of their con- 
tents. The brain-tissue may be stained by the hematin, and occasionally 
presents the appearance of simple non-inflammatory softening. The 
microscope enables us to see a multiplicity of changes — granular degene- 
ration, leucocytes, broken-down nerve-elements, rarely neuroglia-thicken- 
ing, and still more rarely amyloid bodies. I know of no more interest- 
ing field for the study of morbid microscopical anatomy than a brain of 
this kind, for nearly every appearance or grade of diseased structure may 
be found. The vascular lesions are capillary hemorrhage, miliary aneu- 
rism, etc. Suppuration takes place in several ways. The brain-substance 
may be generally infiltrated, so that it presents a yellow color through- 
out its extent, or there may be a localized infiltration or an encysted col- 
lection of pus. About the latter will be found a sclerosis of the brain- 
tissue, and about this a serous infiltration. Jaccoud has found that 
abscesses are more often to be observed in the white substance, in which 



168 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

conclusion he is supported by the observations of many writers. Lebert/ 
in fifty-eight cases, found the abscess to be located twenty-three times in 
the left hemisphere, eighteen in the right, twice in the corpora striata, 
twelve times in the cerebellum, twice in the pituitary body, and once in 
the spinal cord. I have already presented cases which will enable the 
reader to appreciate the origin and size of such collections of purulent 
matter, and the evidences of diseased bone, fracture, etc., that are to be 
discerned in cases of traumatism or disease. In certain pysemic condi- 
tions, such as erysipelas, abscesses may be found in other parts of the 
body as well, notably in the liver and lungs. In rare forms a rapid ne- 
crobiosis or " death " of tissues takes place, which is almost analogous 
with gangrene in other parts of the body, and large masses of brain- 
tissue are destroyed very rapidly. 

Of fifteen cases of cerebral softening of acute form, CalmeiP found in 
one fibrine in the sinuses of the dura mater ; in one, this membrane was 
bathed in purulent liquid, and it was also perforated at one point; in five 
there were recent spots of encephalitis on the right and left sides, in six 
on the left only, in three on the right only ; in three there were cellular 
cicatrices in the right lobe of the brain, in one in the left lobe ; in two 
the right hemis]3here of the cerebellum was the seat of an acute inflam- 
matory spot ; in four the principal recent inflammatory spots were still 
in a state of red hepatization ; in seven they were in a state of softening, 
with disintegration of the nervous substance ; in four they were in. a state 
of disintegration of the nervous substance, with a mixture of a liquid 
that resembled pus ; in four the spots of acute local encephalitis without 
clot were studied microscopically. Of these, in one they were still in the 
state of red hepatization ; the diseased regions were reddened by the 
widening of the capillaries, and by the presence of extravasated globules 
of blood : the cerebral fibres were not yet disintegrated ; already small 
granular cells had begun to be formed in the inflamed parts. In three 
the nervous substance of the diseased seats was disintegrated, and more 
or less reduced to fragments ; it was soaked in plasma, mixed with a con- 
siderable number of great cells collected together, and molecular granules ; 
sometimes in the preparation there were seen rare globules of pus scat- 
tered. The vessels and their principal branches were constantly very 
apparent. 

Diagnosis. — Cerebral hemorrhage, meningitis, cerebral tumor, embo- 
lism, and thrombosis are all conditions from which it is proper we should 
distinguish acute cerebritis and cerebral abscess. 

Some of the symptoms of general paralysis of the insane may possibly 
mislead the observer. From cerebral hemorrhage we are to distinguish 
cerebritis by the rapid amendment of symptoms in the former, while in 
the latter there is progressive evidence of advancing structural changes. 
Fever is not connected with cerebral hemorrhage, unless there be second- 

^Virchow's Archiv, x. 1866. 
2 Quoted by Fox. 



ACUTE SOFTENING. 169 

ary inflammation of the brain-substance. The headache is not sugges- 
tive of cerebral hemorrhage, nor is the delirium or vomiting; and, after 
all, the only symptom which deserves attention is the paralysis. It is im- 
portant to bear in mind that rigidity and contracture take place before 
paralysis, while we know that the converse is the rule in cerebral hem- 
orrhage. Should hemiplegia follow a number of the other symptoms, we 
may consider that the hemorrhage is secondary to the cerebritis, and that 
some vessel has been cut across. It is almost impossible to distinguish 
uncomplicated cerebritis from meningo-cerebritis. The pain is perhaps 
more marked in the. latter, and the convulsions are bilateral, and apt to 
be local, and due to involvement of one or more of the psychomotor cen- 
tres. In uncomplicated cerebritis there is not nearly so much fever as in 
the meningeal form or in simple meningitis. Typhoid fever may simu- 
late cerebritis, and vice versa. Attacks of the latter begin with headache, 
vertigo, movements of the eyfs, insomnia, delirium, nose-bleed, and diarr- 
hoea, with high evening temperature. The absence of tympanites, and 
gurgling in the left iliac fossa, and the appearance of paralysis and visual 
disorders, are quite sufficient landmarks to prevent the diagnostician 
from losing his way. AVhen there is suspicion of otitis or tmumatism, it 
is exceedingly difficult to make a diagnosis from thrombosis of the cere- 
bral sinuses, and it is fortunate that no value is to be attached to such a 
diagnosis, as far as therapeutical indications are concerned. 

Prognosis. — There is very little hope for the patient, and should he 
survive the acute attack he is usually left paralytic and demented. If 
there be a purulent accumulation, which becomes encysted, the chances of 
recovery are very little better, and it only becomes a question of time 
when the patient will die. If there be such a cerebral abscess, subsequent 
symptoms very much like those connected with other brain tumors will 
be probably developed ; but, in numerous cases cited by various authors, 
a cerebral abscess has existed unsuspected for years. 

Treatment.—Acute cerebritis in either form must be met with ab- 
straction of blood, cold effusions to the head, agents which lower vascular 
tension, counter-irritants, and mercury in some one of its forms. The ice- 
bag, or the apparatus already alluded to for the application of cold wa- 
ter, may be used, and leeches are to be applied to the arms or behind the 
ears. Jaccoud and most of the clinical teachers recommend purgation, 
which may be obtained by the use of the compound jalap powder, fol- 
lowed by calomel carried almost to the point of salivation. This seems 
to me to be rather energetic treatment ; and I think that the purgative 
alone, with just sufficient calomel afterward to insure moderate cathartic 
action, is preferable. For the purpose of diminishing vascular tension, 
either tartar emetic, aconite, or veratrum viride may be used. Should 
the cerebritis be found to depend upon syphilis or lead, the iodide of po- 
tassium may be employed as the most serviceable remedy. Blood-letting 
is admissible in serious cases, and is recommended by nearly all of the 
older writers. The head may be shaved and blistered, or cauterized ; but 
I am convinced that sub-occipital vesication is in every way as good, and 



170 DISEASES OF THE CEKEBRUM AND CEREBELLUM. 

the inflictioa of this punishment incident to general cauterization of the 
head is not warranted. Some German writers recommend the application 
to the shaven scalp of tartar-emetic ointment, or croton oil, and claim 
good results. If there be any otitis, it is well to promote otorrhoea; or, if 
there be a collection of pus beneath a depressed and fractured bone, it 
may be liberated by a free incision. 

CHRONIC SOFTENING. 

Definition. — A disease of the brain of a very serious character, gene- 
rally of a secondary nature, and dependent upon impaired nutrition of 
the brain-substance through occlusion of the cerebral vessels, and symp- 
tomatized by a numerous variety of mental, sensorial, and motorial symp- 
toms, such as mania or melancholia and subseqfuent dementia, headache, 
and cutaneous hyperDesthesia and paralysis and convulsions. 

Symptoms. — Much confusion has resulted from the use of a variety 
of terms, such as " red softening, " white softening," '' inflammation of 
the brain," and other names which tend to mislead the student. For our 
purpose it will do to consider white and red softening as different stages 
of the same condition, which may result from a variety of causes ; and 
inflammation of the brain more as the condition which I have just de- 
scribed than that of which I propose to speak, viz., the variety spoken of 
by Reynolds and others as " non-inflammatory softening." The symp- 
toms of softening of the brain may follow a cerebral hemorrhage, embo- 
lism, or thrombosis, or perhaps be connected with symptoms of cerebral 
tumor ; or, again, cerebritis may leave behind it a chronic condition ex- 
pressed by the symptoms I am about to detail. The early troubles of the 
primary form are those of intelligence ; the patient loses his memory of 
events which have recently transpired, is unable to concentrate his atten- 
tion, becomes silly, restless and irritable, quarrelling with his immediate 
friends, and usually getting quite excited towards night. His speech may 
become aflfected, and he sits by himself for hours during the day, and 
mutters constantly a mass of disconnected rubbish. This condition of 
stupidity increases ; he may become drowsy and complain of headache, 
with feelings of head-pressure ; he may tell us that his limbs feel heavy, 
and complains of muscular pain, from which he sufiers in the attempt to 
make any movement. As to other sensory disturbances, hypersesthesia is 
much more common than amesthesia; though cutaneous areas in which 
sensation is impaired, are by no means rare. Motorial troubles are of 
later appearance, commencing with gradual loss of power of an irregular- 
character, which affects either the arms or legs in the beginning, but 
finally becomes general. This paralysis is not always constant, there be- 
ing a greater loss of power at times than at others. The first indication 
of the motorial trouble may appear either in the execution of some ordi- 
nary act, which will be performed very clumsily ; or it may be shown in 
locomotion, when the patient will stumble or fall to the ground, as there 
may be a sudden giving way at the knee. When he walks he scarcely 
lifts his feet from the ground, but drags them after him in a helpless 



CHRONIC SOFTENING. 171 

manner. With the paralysis there may be a certain amount of rigidity, 
or tonic spasms, affecting the muscles, so that there are occasionally spas- 
tic contracti'^ns, which last for some little time. Epileptiform convulsions 
often occur during the disease, as well as attacks of mania, which are quite 
violent. When the softening is secondary, and follows an attack of em- 
bolism, thrombosis, or cerebral hemorrhage, the initial symptoms make 
their appearance in from one to two weeks after the occurrence of the 
hemiplegia. The troubles of intelligence are those which first attract our 
attention, and are" generally connected with high temperature and severe 
headache. The patient may become delirious ; he indulges in delusions, 
and grows abnormally sensitive; or, on the other hand, he is drowsy, stu- 
pid, and melancholic ; and after this may follow paralytic contractures, 
fibrillary contractions, clonic spasms, convulsions resembling epilepsy ; 
and he may finally fall into a state of coma. It is not uncommon for him 
to involuntarily pass his feces and urine. With the formation of cysts or 
abscesses, which constitute a late result of cerebral softening, convulsions 
of an epileptoid character may make their appearance ; or, should the 
condition be acute, and result from otitis, as is the case in cerebritis, 
these as well as other symptoms, may be among the first to develop. Af- 
fections of speech are quite symptomatic of softening, because in so many 
of the cases the middle cerebral artery is that obstructed or destroyed. 
The hemiplegia, which may occur, is unattended by any loss of con- 
sciousness, and electro-muscular contractility is generally perfect or even 
exaggerated. 

The following may be presented as an illustrative case : — 

J. A., aged 45. The patient was brought to me by his wife during the 
summer of 1872. Four years before, while actively engaged in business 
which demanded the most devoted attention, and required a great deal 
of intellectual labor, he began to suffer from headaches limited to the 
frontal region. These were so severe that while engaged in his office he 
was obliged to bind a wet towel about his head. He suffered very 
greatly from insomnia, and found it impossible to sleep unless he took 
large doses of opium. He very often awoke in the night, and went upon 
the house-top or out into the street, wandering about the city until morn- 
ing. He became very moody, treated his wife with indifference, and 
scolded his children without cause. He could not talk for five minutes 
at a time without rising and pacing furiously about the room, while he 
seemed to be annoyed by the slightest noises about the house. ' The trick- 
ling of water from ihe pipe over the water-closet tank, which was next 
to his bed-room, so annoyed him that, in a fit of impatience and un- 
governable irritability, he wanted to send for the plumber in the middle 
of the night. His wife persuaded him to consult a homoeopathic physi- 
cian, by whom he was treated for nearly a year, and at the end of that 
time went abroad. He had meanwhile grown much worse, his mental 
state was much more aggravated, and his headaches, though not so 
severe, were still constantly present. He complained of formication ot 
the soles of the feet, and his gait was markedly affected, both feet being 
scarcely lifted from the ground and he dragged one after the other when 
he walked. He lost rapidly ia flesh, and though the sea-voyage aid him 



172 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

some good, he relapsed into his previous state after he reached Europe. 
While in Switzerland he had an epileptiform attack, and after recovery- 
found that his right side was paralyzed. His speech was affected, and 
from what I can learn he must have been aphasic. The paralysis im- 
proved in a short time, and, strange to say, his mental condition also 
underwent a change for the better. After a few months he returned to 
New York, when I saw him. 

He was then in an almost helpless condition, and needed the assistance 
of a cane and his nurse's arm to make any progress. He was bent over, 
and his chin was depressed, so that it almost touched his chest. The 
mouth was open, and the lower lip drooped slightly ; while from the cor- 
ners of the mouth there Avas an escape of saliva which trickled down over 
his chin. His face bore a very vacant look, and when he attempted to 
speak it was clouded by an anxious and discontented expression, which 
arose probably from the vexation he felt at being unable to speak. Pho- 
nation was not affected, but word formation seemed entirely lost, so that 
his attempts to speak consisted in the production of disorderly noises, the 
tongue being used extensively, the lips not participating. He could not 
protrude his tongue when told to do so. His right pupil was larger than 
the left. His right side was partially hemiplegic, and his wife stated 
that the loss of power was greater at times than at others. The right 
fore-arm was slightly flexed upon the arm, and the fingers seemed rigid. 
His control over the bladder was partially lost, and very often he would 
void his urine while npon the street, or at night. There is a history of 
trembling which affects the right arm and leg. This occurs during quies- 
cence, and seems to have no connection with voluntary movements. - His 
appetite is voracious, but there appears to be some difficulty in swallow- 
ing, so that it is found necessary to cut up his food. About two weeks 
ago he had a slight epileptoid attack. During warm days he seems dis- 
posed to sleep a great deal; but when excited by the presence of disagree- 
able people, or thwarted or crossed, he becomes extremely violent, and even 
dangerous. I saw him but once, and he was afterwards sent to an asylum. 

An extremely interesting form of cerebral disease of this character, is 
that occurring in syphilitic subjects, and attended by narrowing of the 
vessels, with inflammation of their inner coats, the so-called syphilitic 
endoarteritis. There is consequent diminution in nourishment of large 
tracts of brain substance, extensive anaemia and softening. 

The clinical features of such changes are numerous. In some cases 
the symptoms of non-specific thrombosis are presented, but the hemi- 
plegia is rarely preceded by unconsciousness. Epileptiform attacjis, 
severe nocturnal headache, and impairments of the mental powers are 
conspicuous, while a very suspicious indication of the specific nature of the 
trouble is local paralysis of the cranial nerves. The symptoms develop 
sometimes very quickly, and may disappear with great rapidity under 
anti-syphilitic treatment, or on the contrary, if there be much mental 
enfeeblement, I have found the prognosis to be grave in the extreme. 

^ Chauvet, ^ Fournier, and ^ Mickle, and others have described a 

1 Influence de la Syphilis sur les M. dii S. N., 1880. 

^ La Syphilis dii Cerveaii, 1879. 

^ Br and Foreign Med Chir. Ravievv, April, 1877. 



CHRONIC SOFTEXIXG. 173 

spurious form of general paralysis, which is, in reality, a form of cerebral 
softening. It is the same disease as that denominated by Voisin — 
V encepJialopathie sypJiilitique. In this pseudo-general paresis there is 
hebetude, delirium and incoherence. Unlike true general paresis, how- 
ever, the insane delusions do not possess the extravagance of the latter, 
and there is very little of the boasting and inordinate vanity. 

The disorders of motility are not so conspicuous as in the well recog- 
nised disease of non-specific origin, for there is not so much tremor. 
Labial tremor, according to Mickle, is much less common and violent, 
and, he says, that where such tremor exists it is always preceded by 
paralytic troubles, which is not the case in the ordinary paresis. An at- 
tack of hemiplegia is, as a rule, the first indication in the syphilitic subject, 
and the patient presents the peculiar cachectic appearance. A symptom 
referred to in another part of this work, and one which is pathognomonic, 
I believe, is the peculiar asthenic character of the mental trouble. 
There is a true enfeeblement of the intellect, which in some respects, re- 
sembles dementia. Memory, in regard to remote events, appears to be 
blunted, as well as in regard to events that have occurred recently. 
There is not, of necessity, much emotional irritability upon the j)art of 
the patient, although early in the trouble there is sometimes cerebral 
irritation and mental excitement. A disposition to sleep is not rare, and 
such sleep is usually quiet and may even approach stupor. In cases 
of syphilitic cerebral disease of every kind, the careful practitioner 
should be on the lookout for tertiary skin lesions and evidences of early 
general symptoms. In cases I have treated from time to time there 
has been severe neuralgia, which was much more intense at night than 
during the daytime, and besides, the facial and sub-occipital pain there 
has been a sense of vertical head pressure. The localized paralysis may in- 
volve organs which, as a rule, escape involvement in organic disease. In 
three of my cases there has been aphonia as a result of paralysis of the 
vocal cords, and in one of these cases there was, in addition, paralysis 
of the third nerve, and in another, alternating hemiplegia. 

Causes. — First and foremost are primary forms of disease, which 
either produce occlusion of an artery, or irritation from a^blood-clot or 
tumor. Vascular degeneration, which may result from general disease, 
or renal trouble, acts as a predisposing cause in the development of cere- 
bral softening. Intellectual fatigue, sexual excitement, alcoholic intoxi- 
cation, head injuries, and local disease act as exciting causes. Exposure 
to cold has been given as a cause of cerebral softening, and exposure to 
the direct rays of the sun may induce the condition. Bamberger ^ has 
observed it as a consequence of typhus and acute articular rheumatism ; 
and Jaccoud ^ considers that it may be produced by syphilis in two 
different ways, either by a gummy tumor, which gives rise to irritation of 

1 Wiirtzburg Yerhandlungen, 1856. 
^ Pathologie Interne, torn. i. p. 177. 



174 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

the tissue in the neighborhood, or by infiltration. According to Fournier 
and Huebner, syphilitic cerebral trouble may begin as late as the twen- 
tieth year of the disease, and according to the latter, as early as the first 
year, though it is usually until three or four years after the primary 
sore. 

Cerebral softening is more common among people of an advanced life 
as an idiopathic affection, and unless it follows embolism, injuries, or like 
causes, is quite rare in early life, Andral having found only 39 cases out 
of 153 in persons under 40. Darand-FardeP presents the following sta- 
tistics regarding the period of life at which the softening began : — 

From 30 to 40 3 

40 " 50 8 

50 " 55 2 

60 " 65 5 

66 " 70 9 

71 " 75 13 

76 " 80 10 

80 " 87 5 

Jaccoud is of the opinion, which others hold, that males are more 
commonly affected than females. Season has nothing to do with its de- 
velopment. 

Morbid Anatomy and Pathology. —There has been great differ- 
ence of opinion in regard to the pathology of brain softening. Those who 
described it in the early part of the century considered it to be an inflam- 
matory affection, while Rostan,^ who reported many cases, recognized a 
non-inflammatory form which he had met with among old people with 
rigid arteries. As Russell Reynolds^ very properly observes, '' much con- 
fusion has arisen from a tendency to misinterpret morbid anatomical ap- 
pearances, without paying sufficient attention to their mode of origin." 
Cruveilhier* considered two forms, one of which was apoplectic, or " apo- 
plexie capillaire," which he did not consider inflammatory; and, later, 
AndraP announced his disbelief in the necessarily inflammatory origin of 
the disease, and considered it due to occluded arteries and insufficient nu- 
trition. Among the powerful advocates of the inflammation theory are 
Durand-Fardel*^ and Gluge,' while upon the other side may be mentioned 
such additional names as Kirkes,^ Laborde,^ Hughlings Jackson,^" and 
many others. It may be said, I think, that softening of the brain is nearly 
always of an inflammatory character when it follows head injury and dis- 
eases of the cranial bones, while the majority of cases, which are second- 

^ Traite du Eamollisement, etc. Paris, 1843. P. 491. 

2 Becherclies sur le RamoUiseraent du Cerveau, 1820. 

3 System of Medicine, vol. ii. p. 461. * Etivle de la Med., etc., 1821. 
5 Precis d' Anatomic Path., 1829. 

^ Traite du Ramollisement du Cerveau, Paris, 1843. and Maladies des Veillards. 
^ Comptes Rendus, 1837. ^ Op. cit., vol. xxxv. p. 821. 

^ Le Ram. et la Cong, du Cerveau, Paris, 1859. -^° Op. cit. 



CHRONIC SOFTENING, 



175 



ary to occlusion of vessels, are dependent upon general disease of a non- 
inflammatory nature. 

If the disease be primary, Jaccoud considers that the lesion will be of 
the first form, that is, at a single point ; but that when the softening fol- 
lows typhus fever, puerperal, and other general diseases, the foyers will be 
multiple. If the softening results from embolism or thrombosis, or, in 
fact, from any other condition producing obstruction of the circulation, 
there will first be a congestion with exudation of serum, hypersemia of the 
vessels, and perhaps capillary hemorrhage, which is attended by colora- 
tion of the parts in the neighborhood, so that they become of a bright 
pink or red color, and are limited by other regions, which are anaemic 
and blanched, and a condition which has been called " red softening" ex- 
ists. If this morbid process takes place in the gray matter, the hemorr- 
hagic spot will be of a much darker color, and much more sharply circum- 
scribed. The next change takes place within a week or two, when the 
color of the lesion becomes much more pale, and the exudation granu- 
lar; fatty degeneration takes place, the softened spot extends, the 
neuroglia-cells, nerve-fibres, and nerve-cells become disintegrated, the axis 

Fig. 28. 

DiAGBAMM ATIO. 




TfssuE Chasges in Softening. 



A. Vessel. B, B, C. Nerve-tubes. D. Gluge's corpuscles. B. Swol 
nerve-tube. 



cylinders disappear, and the blood vessels alone may be distinguished, and 
even they are greatly disorganized. At this stage the softened spot be- 
comes much paler, is creamy in consistence, and contains stringy flakes of 
a fibrinous nature. It is extremely rare for resolution to take place even 
in the earliest stage. A form of softening, alluded to by Jaccoud, Du- 
rand-Fardel, and others, consists in the formation of yellow plates, chiefly 
in the convolutions (plaques jaunes) which are the result of a partial 
metamorphosis of the softened patches. There may be also a retrograde 
change, as is witnessed in the formation of cysts, which are filled by a 



176 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

chalky fluid containing fat globules. There is always present a variety 
of cells known as Gluge's globules, which are composed of collections of 
small granular bodies, sometimes surrounded by a cell wall, and these are 
produced by the degeneration of neuroglia-cells, the debris of which are 
aggregated as masses of fatty granules. These little bodies, which rarely 
exceed 500 of an inch in diameter, have been found by Keynolds, Turck, 
and Bouchard in the cord, where their form of origin is the same. 

The various (colors may be seen in the brain at the same time, patches 
of red, brown, yellow, or white denoting different stages of the morbid 
process. The lighter shades generally indicate advanced stages, such 
being the opinion of Durand-Fardel. Charcot and various observers have 
found forms of white softening in old people; and others, among them 
Cotard, Prevost, Bastian, and Reynolds have seen cases of the same kind. 
It is extremely doubtful whether the condition of degeneration was not 
preceded by some exudation of blood-elements, and, if it was not, whether 
the condition had not been confounded with sclerosis. Softened patches 
may be in the second stage removed by allowing a stream of water to fall 
upon the cut surface, and when the disorganized tissue is washed away a 
depression is left. If the cut be made through a brain which presents the 
appearance of red softening, the affected patch will be found to stand 
slightly above the normal tissue, and this is probably due to a hypersemia 
of the capillaries of the part. This fulness of the capillaries is undoubtedly 
due to collateral circulation of blood through the vessels contiguous to that 
obliterated, the normal functions being increased through double duty im- 
posed upon them. This is the view held by Vf eber,^ as well as by Prevost 
and Cotard.'^ 

If the yellow appearance of the softened patches be not due to altered 
coloring matter of the blood such as we find in the early stages, it may 
be found later in connection with gelatinous circumscribed masses scat- 
tered through the brain or about old clots or tumors. 

The parts most liable to this change both in chronic and acute forms 
are the corpora striata, optic thalami, white substance of the hemispheres, 
and sometimes the cerebellum ; or there may be multiple foyers scattered 
through different parts of the brain. 

Durand-FardeF has collected sixty-two cases of his own and from the 
WTitings of other authors, in which the locality of the softening was the 
following : — 

Convolutions and white substance 22 

Convolutions alone 6 

White substance alone 5 

Corpus striatum and optic thalamus 6 

Corpus striatum alone 11 

Optic thalamus alone 4 

1 Handbuch der Allgem. und Spec Chirur., 1865. 

2 Gaz. Med. de Paris, May 19, 1866, p. 336. 
5 Op. cit. p. 2. 



CHRONIC SOFTENING. 177 

Pons Varolii 3 

Crus cerebri i 

Corpus callosum 1 

Walls of the ventricles (septum) 1 

Fornix 1 

Cerebellum 1 

The invasion of the brain by syphilis is usually coincident with that of 
other organs, notably, the liver. The morbid process prefers the central 
arteries, but those of small size in every part of the brain may be the 
general seat of inflammation and narrowing, and as a consequence a large 
mass of nervous tissue may be deprived of its nourishment and undergo 
an alteration resembling that which attends non-specific softening. The ir- 
ritation of the syphilitic virus undoubtedly sets up an inflammatory process 
beneath the endothelium of the vessel with deposit of granular substance, 
nuclei and spindle-shaped cells. There is thickening of the endothelium 
and separation of this coat from the others. Subsequent organization of 
the sub-end othelial deposit and division with strata. The vessel becomes 
surrounded by new tissue which is also more or less organized and is ulti- 
mately supplied by capillaries. The next stage is marked by closure of 
the vessel. 

Diagnosis. — In an excellent lecture delivered by Hughlings Jack- 
son/ he says : " I do not see how the diagnosis that there is actual soften- 
ing of the brain is in any case to be possibly arrived at, unless the patient 
has certain local paralytic symptoms, as hemiplegia, or some other symptoms 
implying a local cerebral lesion, such as affection of speech ; or, again, un- 
less there be signs of cerebral tumor (severe headache, urgent vomiting, 
and double optic neuritis) or evidence of injury to the head. For, so far 
as I know, cerebral softening is always local ; I know nothing of general 
or universal softening of the brain. To be warranted in diagnosing soft- 
ening, you must have symptoms which point to local disease. I do not 
say that local cerebral softening cannot exist without localizing symptoms. 
I only say that in their absence you are not warranted in diagnosing its 
existence." This remark is made in connection with the lecturer's disbe- 
lief in various forms of functional disease which are so often improperly 
called *' softening," and in which a few functional symptoms which disap- 
pear under appropriate treatment are vested by the careless or unscrupu- 
lous practitioner with an importance they do not deserve. These symp- 
toms are those which follow depraved states dependent; upon venereal 
excesses, fright, and other causes which lower the tone of the nervous 
system. Jackson's warning is a pertinent one. 

If we have hemiplegia, some renal or cardiac disease, and valvular de- 
posits, with murmurs, our suspicions of softening generally turn out to be 
well founded. The history of the antecedent attack, should it be throm- 
bosis, embolism, or cerebral hemorrhage, has much to do with the making 
of a correct diagnosis. As I have said, hemiplegia, unattended by loss of 

1 London Lancet, Sept. 4, 1875. 
12 



178 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

consciousness at the outset, is a diagnostic point in favor of softening, 
and suggests embolism, and if the train of symptoms given on a previous 
page is afterwards expressed, there can be little doubt as to the nature of 
the disease. A point insisted upon by Jackson is that the general mental 
symptoms of softening are either expressed before the softening, or follow 
it. He denies that general mental symptoms (wandering, delusions, etc.) 
are directly caused by the softening, but that special mental symptoms 
(affection of speech) are. The general mental symptoms follow a few 
hours or days after the local softening. The ^^ preceding mental symptoms " 
are irritability and altered disposition. 

Chronic meningitis may resemble cerebral softening, but in the former 
the pain is more diffused, and the motorial phenomena (spasms, etc.) are 
more pronounced. Softening with tumor may be made out from the ad- 
ditional presence of optic neuritis, choked disk, and vomiting. Some 
forms of progressive meningitis, such as pachymeningitis with cerebral 
hsematoma (vide the case detailed in the chapter upon pachymeningitis), 
may closely simulate cerebral softening, and very often the diagnosis is 
exceedingly difficult, or may be impossible. The symptoms of hemor- 
rhage from rupture of a meningeal vessel, such as occurs in the course of 
these chronic varieties of nieningitis, may closely counterfeit the apoplec- 
tic attack which occurs so often in cerebral softening. 

Prognosis. — Cerebral softening is one of the most unfavorable con- 
ditions with which we are acquainted. Death follows the establishment 
of the morbid condition sooner or later in nearly all cases occurring in 
adult life. An occasional case of recovery may be encountered in a young 
subject, but this is exceptional. Of 109 cases of both forms of cerebritis 
collected by Aitkin,^ he found that the duration of life in cases of this 
disease was i the following, which also proves that there are more cases of 
the acute than the chronic form of the disease. 



1 died 


in 12 hours. 


2 


died 


in 12 days. 




died 


in 30 


days. 


1 


15 


(( 


3 


(C 


13 


(< 




" 


36 


a 


1 


24 


(( 


3 


a 


15 


C( 




(( 


47 


U 


1 


32 


(( 


1 


Ci 


16 


l( 




a 


49 


" 


5 " 


2 


days. 


2 


ii 


17 


(<■ 




i( 


60 


t( 


9 


3 


(( 


4 


ii 


18 


IC 




a 


65 


il 


5 


4 


«< 


5 


u 


20 


a 




(I 


68 


■ << 


4 '' 


5 


<( 


3 


a 


21 


i( 




(. 


190 


" 


7 


6 


ii 


1 


(I 


12 


11 




(( 


220 


(< 


8 " 


7 


u 


1 


(( 


23 


(i 




(( 


5 


months 


8 


8 


(I 


1 


it 


25 


It 


2 


(( 


6 


(( 


3 


9 


(i 


1 


u 


29 


f( 


1 


(I 


1 


year. 


5 " 


10 


<t 


4 


• i( 


30 


(I 


2 


a 


3 


years. 


4 '* 


11 





















The greater number of these patients died, it will be seen, before the 
twelfth day. 

The experience of other observers is slightly different from this, as 

^ The Science and Practice of Medicine, vol. ii. p. 304. 



ASEMASIA. 179 

many persons with secondary softening Have been found to live for years 
after the commencement of the softening. These cases being all fatal, 
we have to remember as well that there are many instances in which 
an abscess forms and becomes encysted, or the non-inflammatory soften- 
ing circumscribed. 

In syphilitic arterial disease the prognosis is bad when the mental 
symptoms are at all prominent ; but, light symptoms chiefly of cerebral 
irritation, which indicate the beginning of the morbid process described 
upon another page, are sufficiently suggestive to enable us to give the 
patient encouragement, and to expect benefit from energetic anti-syphili- 
tic treatment. 

Treatment. — Our efforts should be to improve, as rapidly and fully 
as possible, the patient's general condition. For this purpose we must 
not only prescribe for him a hearty hydrocarbonaceous diet, but we are 
to insist upon cold-bathing, out-door exercise, and moderate stimulation. 
As medicaments, I am positive that there is no better remedy than phos- 
phorus, which may be given in combination with cod-liver oil, or in solu- 
tion in absolute alcohol. The bromides may be given in combination 
with lupulin, if there be headache or delirium ; or cannabis indica, as 
recommended by Reynolds. If the bowels be sluggish, a free use of 
saline cathartics is of great benefit ; and to relieve the head symptoms, 
leeching may do much good. In the chronic form tonics are indicated, 
and for this purpose I prefer the ammonio- citrate of iron. I am not in 
favor of strychnine, and should hesitate to use it if the case were at all 
acute. 

For the relief of the syphilitic form of disease we may follow the treat- 
ment insisted upon by Dr. Taylor and others — "iodine and mercury in 
heroic doses." 

The iodide of potassium should be employed in commencing doses of 
fifteen grains, and, if borne well, may be increased even to one drachm 
three times a day. This drug should be given well diluted and after eat- 
ing. Simultaneous inunction of mercurial ointment greatly helps the 
action of the iodide. 

ASEMASIA^ (APHASIA). 

Synonyms. — Aphemia, Alalia, Laloplegia, Paralalie, etc. 

Definition. — We may define aphasia (which is derived from the 
Greek a, priv., and (paati:, speech) as a partial or complete loss of speech, 
which does not depend upon any vocal or lingual impairment of func- 

1 It has occurred to me that the word " aphasia," as at present used, has too re- 
stricted a meaning to express the various forms of trouble of this nature, which not 
only consist of speech defects, but loss of gesticulating power, singing, reading, 
writing, and other functions by which the individual is enabled to put himself in 
communication with his fellows. I would, therefore, suggest ''asemasia" as a sub- 
stitute for " aphasia." The word is derived from d and C7jfj,aivu, (an inability to 
indicate by signs or language). 



180 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

tion, but upon disease of the speech-centres, whereby the origination of 
forms of expression is suspended or deranged to a greater or less degree, 
or a kindred loss of writing or gesticulating power. Aphasia must not 
be confounded with aphonia, or with the condition met with in idiots or 
mutes. The disease we are about to consider is seated, as it is generally- 
conceded, in the third frontal convolution, and is characterized by the 
disruption of the connection between the formation of ideas and their ex- 
pression by the lingual apparatus ; or, as Broca has expressed it: " Le 
mot aphasie sert aujourd'hui a designer la perte ou la perversion de la 
faculte du langage ; en generale c'est de cette faculte que nous permet 
d'etablir une relation constante entre une idee et une signe, que ce signe 
soit un mot, un geste, ou un trace quelconque." This loss of function 
varies from temporary trouble, such as the substitution of an occasional 
wrong word, to a condition of decided intellectual abasement. It will be 
well, before discussing the subject further, to say a few words in regard to 
the history of this interesting disease. Our first information comes from 
very early writers, among whom were Sextus Empiricus,^ who lived two 
hundred years before Christ, and Pliny. Trousseau (p. 253) quotes the 
latter : " Illness, falls,, a mere fright, impair it (memory) partially, or 
destroy it completely. A man struck by a stone forgot the letters of the 
alphabet," etc. Later, Sauvage,'^ Cullen,^ and the two Franks* wrote 
most exhaustively during the seventeenth and eighteenth centuries, but 
all of these authors devoted more attention to mutism, aphonia, and like 
conditions, than to aphasia. In 1840, Lordat,^ who, strange to say, be- 
came aphasie himself, described the disease under the name of alalia, a 
term used by Jaccoud at the present day. Though Gall,^ as early as 
1808, localized the speech-centre above the orbits, it was not till 1825 
that its pathology and morbid anatomy were clearly settled by Bouil- 
laud,^ who, working upon Gall's theory, enunciated the doctrine that 
" the anterior lobes of the brain are the organs for the formation and 
recollection of words, or the principal signs which represent our ideas." 

Afterwards, Bouillaud's views were nevertheless opposed by Andral,^ 
Cruveilhier,^ and others, to whom I shall hereafter allude. Experiments 
made by Marce in 1856, and by others, confirmed all that Bouillaud had 
stated. The next step was taken by Marc Dax^" in 1836, and by his son, 

^Translated work by Huart, Amsterdam, 1725, p. 93. 

^Nosologia Meth., Paris, 1722, t. ii., class 6, p. 249. 

^ Synopsis Nosologic Meth., edited by Frank, 1787. 

* De Curandis Horn., Mannheim et Vienna, 1792-1821. 

5 Analyse de la parole pour servir a la th^orie du divers casd'alalieet de paralalie, 
etc., Montpellier, 1843. 

^Sur les Fonctions du Cerveau, Paris, 1825, t. v. 

^ Treatise on Encephalitis, p. 284. 

8 Maladies de I'Enc^phale (Clin. Med., 1834, t, ii.). 

^Sur le principe legislateur de la parole (Bull, de T Academic, 1839). 

^^^ Lesions de la moitid gauche de I'encephale coincidant avec I'oubli des signes de 
la pensee. Memoir read at the Congres M^dicale de Montpellier, 1836 — Gaz. Heb., 
April, 1865. 



ASEMASIA. 181 

who confirmed his observations in 1863. It was the younger Dax who 
demonstrated that aphasia was connected with right-sided paralysis ^ 
Broca^ next limited the spot to the second or third frontal convolution. 
Since then Hughlings Jackson,^ Jaccoud/ Trousseau,^ Dieulafoy,^ Gaird- 
ner/ and many others have added much to the interest of the subject. 
There has been considerable discussion as to the proper name for the af- 
fection. Lordat, to whom I have already alluded, preferred " alalia ;" 
and others, among them Broca, denominated the condition " aphemia." 
The word is still used by some writers ; but the term " aphasia " has come 
into general use, and is generally conceded to be much more expressive 
and proper than any other, but it has, I think, been too indiscriminately 
employed. 

Jaccoud, who has rather added to the confusing nomenclature, presents 
a table, which embodies nothing new, and, if anything, increases the iodefi- 
niteness of our knowledge of the disease. Aphasia, or more properly ase- 
masia, is most protean, as it may involve the power of reading aloud, speak- 
ing, writing, and gesticulating, in part or together, in a number of curious 
ways. Let us then consider the phenomena which mark its existence. 

Speech. — The vocabulary of the aphasic patient is generally of the most 
limited kind, and in the beginning, should the condition follow a cerebral 
accident of any magnitude, his power of speech is totally absent. After 
a while he may be able to command one or two short phrases, or such 
words as "yes" or ''no" in reply to every question that may be asked. 
These words, or such as have become automatic from constant use, are 
employed, and it is very curious sometimes to hear the patient give utter- 
ance to some phrase which, during health, he has constantly and some- 
times unconsciously made use of In other instances several words may 
be joined together in an incongruous manner ; for example, it was ob- 
served, in a case I detailed when speaking of cerebral thrombosis, that 
the patient replied " When Benny" to the question " where do you live?"^ 

^Sur le siege de la facalte du langage, etc. (Bull, de la Soc. Anat., 2e, Serie, t. iv., 
1861). 

^Gaz.Heb., April 28, 1865. 

=^Eep. London Hospital, vol. i., 1864, p. 388. 

* Gaz. Heb. July and Aug., 1864. 

5 Clin. Med. de I'Hotel Dieu, t. ii., p. 571. 

^ Gaz. des Hop., June, 1865. 

'Arch, de Med., t. ii., pp. 189-814, 1869. The reader is referred to the admirable 
thesis of Legroux (A. Delahaye, Paris, 1875), for a more complete bibliography of 
the subject. 

^ Numerous interesting cases are reported. One described by Osborn* is illustrative 
of a form which is sometimes met with. The patient comprehended written language, 
and expressed himself in writing, only occasionally transposing words. He could 
translate fluently, and was able to calculate arithmetical sums. He could not pro- 
nounce the letters "^', g, w, v, w, z, and 2," and the letter ''t" seemed to puzzle him. 
Dr. Osborn requested him to read the following sentence from the By-Laws of the 
College of Physicians : " It shall be in the power of the college to examine or not any 

* Forbes Winslow, Obscure Diseases of the Mind, p. 343. 



182 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

Durand-Fardel alludes to a patient who always gave the following absurd 
answer : " Madame ete, mon Dieu, est-il possible, bon jour, madame." 
Legroux^ remarks in regard to these forms : " It is to be supposed in these 
cases that the patients speak without hearing what they say, or that their 
auditory receptivity is unable to reveal the imperfection of their speech." 
Occasionally, however, the aphasic is conscious of the absurdity of his 
reply ; he will laugh in a silly manner, or appear annoyed or worried, for, 
in a majority of cases, there is perfect mental integrity, and the position 
of the patient is very like that of a man driving a runaway horse. It 
has often reminded me of a condition which I have more than once ex- 
perienced myself, and which is by no means uncommon, — the confusion 
of the mind during nightmare. When the individual is about to 
awake he is semi-conscious of the unsubstantial character of the impend- 
ing danger of the dream, but cannot save himself nor can he awake. 
During the nightmare a person may actually spring from the bed, or 
make some other voluntary attempt to escape. Lordat, who was aphasic, 
gave, after his recovery, an account of the inward sensations that he 
felt during his illness, and which perfectly indicate the part played by 
memory. He could think, he could co-ordinate a lecture, or change its 
arrangement in his own mind, but he was unable, although he was not 
paralyzed, to express his thoughts in speaking or writing. " I thought," 
said he, " of the Christian doxology, ' Glory be to the Father, the Son, 
and the Holy Ghost,' and I was not able to recollect a single word of it. 
Thoughts seemed to arise freely, but the mode of expressing them in 
sounds, the receptacle of these thoughts, was forgotten."'^ The words 
which are generally lost, and are the latest to be acquired, are the pro- 
nouns and substantives, while those which the individual retains the 
power of articulating more than any other are the interjections, such as 
" Oh !" ''oh, dear !" " ah, yes !" It is not rare for patients to exhibit two 
other peculiarities ; one is a substitution of other words for those intended, 
the second is a conjunction of incongruous syllables; for instance, a pa- 
tient may say " bel-eb " for " belief," or, as in the case reported by Trous- 
seau, " bon-tif " was substituted for " bonsoir." Some persons are able to 
repeat words which are first pronounced for them by another, but are un- 
able a minute afterwards to articulate the desired word. A patient of 
my own, when requested to tell what it was he held in his hand, could not 
say. When asked if it was a paper he shook his head ; an apple ? 
another shake, and a shrug of the shoulder ; a cane ? a pitying smile, and 
a gesture of impatience ; a book ? a bright smile, and the immediate ar- 

licentiate previous to his admission to a fellowship, as they shall think fit." The re- 
sult was as follows : " An the bi what in the temother of the tro tho todoo to ma- 
jorum or that emidrate ein einkrastrai mestreit toketra to tom breidei to ra from- 
treido as that kekritest." It is rare, however, for a patient to accomplish as much as 
this. He generally becomes impatient, and gives up the attempt after half a dozen 
imperfect words. 

^ De 1' Aphasie, p. 15. 

2 Trousseau's Lectures on Clinical Medicine, vol. ii. p. 273, last Am. edition, 1873^ 



ASEMASIA. 183 

ticulation of the word " book." " What did you say it was ?" To which 
there was a puzzled look, an attempt to speak, and no answer. Jackson 
and others have alluded to striking examples of this defect. Bastian ^ 
alludes to a form in which there was transposition of the letters, the pa- 
tient saying "gum" for "mug." Patients are very apt to substitute 
words. Thus, when one was asked if he wanted to sit down, replied : 
" Give me a bottle, I want to rise down." Bauduy ^ alludes to a case where 
the connection was better shown. The man asked for a " cup of cow!" 
Some aphasics, though they may be utterly unable to speak, can sing. 
Hughlings Jackson^ alludes to two aphasics, boys, one eight and the other 
ten, who could sing. Bacon reported the case of an idiot boy who was 
aphasic, but could sing quite cleverly. These cases are very rare, but in- 
teresting examples are occasionally brought forward. Behier reports the 
case of a sailor who could sing the Marseillaise, using the word " tan ** 
throughout. 

Writing. — The aphasic individual who cannot speak is occasionally 
able to write, but, in my experience, I have generally found the loss of 
these faculties (speech and writing power) to co-exist. This variety, 
which has been called agraphia by Ogle, has been divided by him into 
the anemonemic and atactic varieties. We may meet with the same 
peculiarities which attend the form I have already alluded to, viz. : sub- 
stitution of words or letters. The patient may be able to write after a 
copy, but this is rare. He takes his pen and begins quite confidently, but 
as soon as the pen touches the paper he makes a series of scrawls, which 
rarely bear any resemblance to the letters forming the words he is re- 
quired to write. 

Bourneville "^ relates a case : " A woman named Justine Thomas enter- 
ed the hospital La Pitie December 15, 1870, and was assigned to the ser- 
vice of Marotte. She became hemiplegic on the right side, and had com- 
plete aphasia. On the 18th of December the hemiplegia had nearly dis- 
appeared, but the aphasia persisted. At this time she was asked to write 
her name, and only succeeded in producing the appearance presented in 
the accompanying cut (Fig. 24, A). At different times during the year 
specimens of her handwriting were taken, which showed progress and 
marked improvement, the last attempt being made in November^ 1871. 
(Fig. 24, B.) This lost power must not be confounded with other con- 
ditions symptomatic of insanity or sclerosis and the element of paralysis,, 
which should be taken into account if there be any suspicion of a loss of 
muscular power. A hemiplegic may be unable to write simply thuough 
muscular weakness and difficult muscular coordination. Of course time 
will enable us to see whether the inability to write is due to this cause, 
or is really the " agraphic " condition. Beading, singing, and the power 



^ Med. Chir. Kev., xliii. p. 209. 
'^ Lancet, 1871, p. 430. 
^ Diseases of Nervous System, p. 412. 
* Legroux's Thesis. 



184 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



of gesticulating are lost either separately or together. A person who 
cannot speak is sometimes able to sing. So, too, in reading. He may 

Fi^. 24. 




read mechanically without appreciating the sense, or may drop his words 
or substitute others, and perhaps is unconscious of his mistake. He may 
be unable to read, but may show by signs that he knows what such and 

Fig. 25. 



Handwriting of two patients: "A" being affected with agraphia, and "B" with cerebrospinal 
sclerosis. The first specimen is intended for " Possible to see you on Tuesday." The second, 
" Dieu et mon Droit." 

such a picture may be. The power of gesticulation may be, and often is, 
lost. He may make attempts to describe the figure of some object, but 
cannot do so. Trousseau related the case of a person who was told to 
imitate the playing of a clarionet, but when he attempted to do so beat 
instead an imaginary tambourine. He is sometimes able to count figures 
which are before him, or pieces of money put in his hand, but if he has 
no such reminders, and is simply told to count, he may be able to count 
up to a certain number, and say ten, and does so in a peculiarly auto- 



ASEMASIA. 185 

matic way. After this, when some thought is required to make combi- 
nations, the effort is unsuccessful. 

For the purpose of making himself understood it is necessary that an 
individual should be familiar with signs (visual and auditory), which have 
been received either upon the retina or tympanum, and reflected upon 
certain ideational and receptive centres, where they are retained and 
serve as models for expressions the individual may wish to make in the 
iiiture. The mental process which attends the formation of language or 
the communicating faculty becomes so intricate and automatic that insen- 
sibly the process of comparison and centre stimulation goes on without the 
knowledge of the person, and words and signs are made upon the ground- 
work of impressions previously received for guidance and formation. It 
is only when disease affects the particular centre that the harmony is lost, 
and the patient, though possessing the ear and eye as mentors, is unable 
to co-ordinate the mental factors of intelligible communication. The fa- 
cility for connecting ideas with sounds or signs, which is a normal faculty, 
is thus spoken of by Ogle : " This faculty of converting ideas into symbols 
is quite distinct from that of converting symbols into ideas. The one may 
be acquired or lost independently of the other. Thus, a child learns to 
interpret the language of others before it can itself speak. Adults, as a 
rule, follow the same order in learning a new or foreign language. Most 
of us, moreover, know what it is to have the pictured map of some familiar 
object in our minds, yet to be perfectly unable to call up its^name." This 
defect has hitherto been supposed to depend not upon the apparatus for 
the receipt of impressions, nor upon the apparatus for communication, but 
upon a loss of function in what has been called the " central organ of 
articulate speech," and that both the inability to remember words and 
connect them with ideas, and the inability to compel the organ of articulation 
to form words, depend upon some change only at this point. Modern 
physiology has taught us, however, that though the organs of reception 
may be healthy, there are certain cortical regions in relation therewith 
which seem to have a connection with the island of Reil as well, and 
through recent disease new perceptions cannot revive the impressions 
received previously in the healthy state, which have become the basis of 
ideas, nor can the *^ organ of articulate speech" be made to act, though 
unaffected itself. The loss of power to express ideas is symptomatized by 
aphasia, agraphia, or other defects in the communicating faculty. If there 
be amnesia, the central disturbance (whatever it is) is the same, and the 
variation of lost means for expression depends on the manner of separa- 
tion of organs from mental control. There seems to be little doubt as to 
the seat of this centre, and as to the circumstances under which it is im- 
paired. The collected cases of different authors mainly go to show that 
the left side of the brain is the seat of a lesion in its anterior part, and 
that the third frontal convolution is the one most constantly involved. I 
have already casually referred to Broca's investigations, and will now 

^ Journal of Mental Science. 



186 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

present his description, which has been modified by Bateman/ of its anato- 
mical seat/ " The anterior lobes of the brain comprehend all that part of 
the hemisphere situated above the fissure of Sylvius, which separates it 
from the temporo-sphenoidal lobe and in front of the furrow of Rolando 

(R. R.) which separates it from the parietal lobe The direction of 

this furrow is almost transverse ; setting out from the median line, it con- 
tinues almost in a direct line, and after describing some flexuosities ter- 
minates below and outside of the fissure of Sylvius, which it meets almost 
at a right angle behind the posterior border of the lobe of the insula. 

"The anterior lobe of the brain is composed of two divisions, the one 
inferior, or orbital, formed by the several convolutions called orbital, which 
lie on the roof of the orbit, and of which I shall not have to speak ; the 
other, superior, situated under the outer wall of the frontal bone, and under 

Fig. 26. 




the most anterior portion of the parietal. This superior division is com- 
posed of four fundamental convolutions called, properly speaking, i\iQ fron- 
tal (convolutions ; one is posterior, the others are anterior. The posterior, 
FF, slightly tortuous from the anterior boundary of the furrow of Rolando. 
It is therefore almost transverse, and ascends from without, inwards, from 
the fissure of Sylvius to the great median fissure, which receives the falx 
cerebri of the brain. This is why it (F F) is described indifferently under 
the nsimefroiital, posterior, transverse, or ascending convolution. The other 
three convolutions of the superior division are very tortuous and very 
complicated, and some practice is needed to distinguish them in all their 
length without confounding the fundamental furrows which separate them 
with the secondary furrows which separate the second order folds, and 
which vary in different individuals according to the degree of complica- 

^ The reader may also consult Morel's Plate, presented upon a previous page. 



ASEMASIA. 187 

tion ; that is to say, according to the degree of development of the funda- 
mental convolutions. These three fundamental convolutions, 1, 2, 3, are 
antero-posterior, and, running side by side, extend from before backward 
over the whole length of the frontal lobe. They commence on a level with 
the superciliary arch, whence they are reflected, to be continuous with con- 
volutions of the inferior division, and terminate behind in the frontal trans- 
verse convolution, F, F, which all the three enter. They are called first 
(1), second (2), and third (3), frontal convolutions. They may also be 
called internal (1), middle (2), and external (3) ; but the ordinary names 
have prevailed. The first (1) runs along the great fissure of the brain ; 
it presents, constantly, in the human species, an antero-posterior furrow 
more or less complete, which divides it into two folds of a second order ; it 
has, therefore, been divided into two convolutions, but comparative anato- 
my shows that these two folds form only a single fundamental convolu- 
tion. The second (2) frontal convolution presents nothing peculiar ; not 
so with the third [ 3), which is more external. The latter presents a su- 
perior or internal border, adjoining the tortuous border of the middle con- 
volution (2), and an inferior or exterior border, the relations of which 
differ according as they are examined before or behind. In its anterior 
half this border is in contact with the external border of the most exter- 
nal orbital convolution. In its posterior half, on the contrary, it is free 
and separated from the temporo-sphenoidal lobe by the fissure of Syl- 
vius, S, S, of which it forms the superior border. It is in consequence of 
this latter relation that the third frontal convolution is sometimes called 
the superior marginal convolution. 

** Let me add, that the inferior border of the fissure of Sylvius (S, S) 
is formed by the superior convolution of the temporo-sphenoidal lobe, 
which is therefore called the inferior marginal convolution T, T. It is 
an antero-posterior fold, thin, and almost rectilinear, which is separated 
from the temporo-sphenoidal convolution T 2, T 2, by a furrow parallel 
to the fissure of Sylvius. This furrow is described under the name of the 
parallel fissure (with reference to the fissure of Sylvius, S, S). Lastly, 
when the two marginal convolutions, superior, 3, 3, 3, and inferior, T, T, 
are drawn away from the fissure of Sylvius, S, S, there appears an en- 
larged and slightly prominent eminence, I, from the summit of which 
five small simple convolutions, or rather five straight folds, radiate in a 
fan-like manner. It is the lobe of the insula which covers the extra- 
ventricular nucleus of the corpus striatum, and which, arising from the 
bottom of the fissure of Sylvius, S, S, is found to be structurally con- 
tinuous by its cortical layer with the deepest or most deeply seated part 
of the two marginal convolutions, 3, 3, 3, and T, T, and by its medullary 
layer with the extra-ventricular layer of the corpus striatum. The re- 
sult of these structural relations is, that a lesion which propagates itself 
continuously from the frontal lobe to the temporo-sphenoidal lobe, or, 
vice versa, will pass almost necessarily by the lobe of the insula, and 
that from thence it will most probably extend to the extra-ventricular 
nucleus of the corpus striatum, since the proper substance of the insula 



188 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

I, which separates the nucleus from the surface of the brain, forms only 
a very thin layer." 

Not only may a lesion of the speech-centre itself produce aphasia, but 
in numerous instances (some of which have been referred to by Jackson) 
it may follow the destruction of adjacent parts, as a consequence of some 
such accident as the plugging up of the middle cerebral artery. As a. 
consequence of such a pathological condition, a large area of brain sub- 
stance will be destroyed, so that impaired mental function as well as 
aphasia takes place. We shall presently see that though this particular 
part of the third frontal convolution is the seat of the organ of " speech 
expression," there are other important cortical regions which, when de- 
stroyed, give rise to asemasia. 

An important subject in this connection is the side of the brain which 
is aifected. Though exceptional cases have been reported in which the 
right cerebral hemisphere has been the seat of the lesion, the rule is the 
other way. In some instances, even, no lesion whatever has been found ; 
or, on the other hand, the left anterior convolutions have been the seat 
of morbid change, and no loss of speech has been occasioned. Simp- 
son^ has related one case where marked destruction of the left an- 
terior lobe was observed, and yet no aphasia existed. This man, aged 
65, who had been epileptic for ten years, having as many as three or 
four attacks a month, died. The white and gray matter of the left 
hemisphere were markedly atrophied, and there was a cavity in the left 
posterior frontal convolution of If inches longitudinally, and li trans- 
versely. 

The following case is interesting, as it shows that almost complete 
aphasia may exist without any disease of the island of Reil : — 

M. A. B., aged thirty-five years, married. Family and previous per- 
sonal history good, but it is possible to trace syphilis. The patient had 
an apoplectic attack in August, 1859, with loss of consciousness, which 
lasted for two hours ; on recovery it was found that she was unable to 
speak, but there was slight improvement after a few months. Present 
condition, July 17, 1874 : The patient is a middle-sized woman of seem- 
ingly good condition, with the exception of her nervous trouble. There 
is slight paralysis of the left side ; can move left arm well, but slowly, 
and walks with a shuffling gait. Tactile sensibility, and sensibility to 
differences in temperature, are decidedly impaired on the left side, on 
which side there is an appreciable amount of analgesia. She protrudes 
her tongue in a straight line, but feebly. No loss of taste or smell. 
Her mental condition is below the average. The first part of her his- 
tory I have taken from the records of the Epileptic and Paralytic Hospi- 
tal, and I also find that for some months she has been sufiering from 
symptoms of phthisis. AVhen I saw her on August 10, 1875, the patient 
was in advanced phthisis ; her nervous condition was the following ; 
Paralysis of the left side ; her left hand lies in her lap, the thumb being 
contracted and flexed ; the flexor tendons of the hand are rigidly con- 

1 Med. Times and Gazette, Dec. 21, 1867. 



ASEMASIA. 189 

tracted, so that at the wrists they stand out like tense cords. There is 
very little atrophy of the left upper extremity, but there is a certain stiff- 
ness about the elbow-joints of this side. The left lower extremity seems 
to be nearly as strong as its fellow. Motion at the hip and knee-joints is 
limited. She can raise her foot from the ground when sitting, but when 
she walks it is in a shambling manner, dragging her left foot, or scarcely 
lifting it from the ground. There is some paralysis of the left side of 
the face, and it is impossible for her to protrude her tongue. Sensibility 
seems to be very slightly affected in the paralyzed side. She is almost 
completely aphasic, her repertoire of words being confined to " yes " and 
" no," the former being repeated several times in answer to any ques- 
tions she may be asked. When she is asked her name, she is unable to 
tell it. " Is it Jane ?" she shakes her head and smiles. " Is it Ann ? ' 
another shake of the head, and an attempt to speak, the only result being 
the production of an unintelligible noise. " Is it Mary ?" when she 

brightens up and says, " Yes, yes, yes ; Ma " prolonged, and she 

generally gives it up in disgust. She cannot write, but makes a disor- 
derly scrawl ; although we learn from her friends that in health she wrote 
well. She gesticulates a good deal, and endeavors to attract the atten- 
tion of those in the ward, and evidently appreciates everything that 
goes on about her. Her pupils are easily dilated, but she does not see 
with the right eye, and on examination I find atrophy of the optic disk. 
During the winter and spring of 1875-76, she seemed to suffer much from 
her pulmonary trouble. There was oedema of the lower extremities, which 
increased so that the anasarca became general, but she was somewhat 
relieved by digitalis and iron ; diarrhoea supervened, and she finally died 
on the second day of June, 1876. 

Autopsy. — The dura mater was considerably thickened, and presented 
the appearance of old pachymeningitis. There was no lesion to be dis- 
covered in either third frontal convolution, but an old clot was found in 
the right caudate nucleus. This clot was about half an inch in diameter, 
and was surrounded by some dense tissue. Cortical lesions were present 
on both sides of the brain, but of superficial extent, and confined chiefly 
to the parietal convolutions ; these consisted of softened patches in ad- 
vanced stages of degeneration. The cerebral arteries contained patches 
of a yellowish or atheromatous nature. The spinal cord was not exam- 
ined. Both lungs were found to be tubercular, and in the middle lobe of 
the right there was a large cavity. I was unable to find any tubercular 
deposit whatever in the brain or its meninges. The left frontal convolu- 
tions were examined, but no disease whatever was found, and the occipital 
convolutions were in normal condition. 

Hemingway reports the following interesting case of left-sided paralysis 
with aphasia : ^ 

Jane E., aged 30, widow ; occupation seamstress ; education fair, can 
read and write. Entered hospital October 30, 1873. Family history 
good ; says she always was a healthy woman till present illness. Admits 
having had a sore on genitals five years ago. Cicatrices are at present 
visible on forehead, which are probably a result of tubercular syphilides ; 

1 Medical Eecord, March 4, 1876. 



190 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

says they came there five years ago. Her left eye shows the result of an 
old ophthalmia, which, it was supposed, was of gonorrhoeal origin. For 
two years past has had slight palpitations on exertion. Always used her 
right hand in her occupation. Four months ago, one night when she was 
going to bed she became suddenly speechless ; there was no paralysis 
whatever. Next morning, on attempting to arise, found her left arm, leg, 
and side of face paralyzed ; also, with loss of sensation in those parts. 
Loss of speech was complete ; and hearing, which before this was excel- 
lent, was now lost in left ear. Her tongue was only afiected in sensation; 
she was not able to appreciate sweet substances placed on the tongue ; 
sense of smell also lost. About one month after this attack, i. e., three 
months ago, improvement began in speech, face, and lower extremity, 
and has continued since then. Upper extremity began to improve one 
month ago. Sphincters have not been afiected. Is a medium-sized wo- 
man, pretty well nourished ; mental faculties good, with exception of loss 
of memory, constituting well-marked amnesic aphasia. Is unable to re- 
collect many words, names of objects, as hat, key, handkerchief, pencil, 
etc. ; though she can readily repeat them on being told, she forgets them 
immediately afterwards. Is unable to read continuously, omitting words, 
and giving up from inability to fix attention. On attempting to write 
the letters of the alphabet, the result was ABCDSGHI; but when 
the letters w^ere. separately told her, she wrote them down easily. Partial 
paralysis remains on left side of face ; cannot close eyelids tightly. Sen- 
sation is lost to a great extent on left side of face, and in left nostril. 
Does not wince on the application of aqua ammonia to left nostril, nor 
when the conjunctiva on same side is touched with an irritant. Hearing 
poor on left side. Taste is impaired anteriorly and posteriorly on left 
side of tongue. 



Dynamometer, \ 'o-ht 8o' ( outer circle. 



^sthesiometer is valueless, on account of loss of sensation, of reaction 
to pain. Does not wince on pinching arm, but does on palm of hand and 
tips of fingers. Perception delayed ; takes about three seconds. Can 
raise arm to level of shoulder, a little stifily. Can flex and extend fore- 
arm and fingers, but slowly. Heart sounds normal. Walks without elas- 
ticity. Sensation in leg as in arm. Reflex action lessened. Electro- 
muscular contractility good. 

The accumulation of reported cases, however, in which the lesion was 
on the left side, leaves no doubt in regard to this question. Jackson and 
Ramskill report 40 cases of right hemiplegia with aphasia, and but one of 
left hemiplegia. Ogle^ reports 25 cases all with the lesion in the left 
hemisphere, though there were morbid changes in some of these in other 
parts. In not one of these where the lesion was on the left side was 
there undisturbed speech. Magnan ^ reported thirty-one cases of aphasia, 
and in all but four was there right-sided hemiplegia. Trousseau, in 1868, 
had collected all the cases he could find, the number being over one 
hundred, and in all but ten there was right-sided paralysis. Seguin^ has 



^ St. Geo. Hosp, Reports, vol. ii. 
^ Bull, de TAcademie de Medecine. 



Quarterly Journal of Psychological Medicine, 1861, xxx., 663. 



ASEMASIA. 191 

collected 46 cases from the records of the New York Hospital, and in all 
but three there was right hemiplegia. Thus it is settled, I think, that 
the left side of the brain is that which contaius the speech- centre. 

The question as to the relative frequency of right and left hemiplegia 
naturally arises, and from the inspection of a large number of cases it will 
be seen that there is a very slight preponderance of the former. 

Browne,^ from Baillarger's tables, says that " in aphasia right is to left 
hemiplegia as 15 is to 1." 

By the following table it will be seen that there is very slight prepon- 
derance of right-sided paralysis, and the comparison between the infre- 
quency of aphasia with left hemiplegia, and the slight differeuce between 
the relative frequency of occurrence of both forms, is inconsiderable. 

Cases of hemiplegia. K. L. 

Ogle 75 43 32 

Andral 136 73 63 

. Baillarger 110 58 52 

321 174 147 

As to the exact site, Seguin tabulates 545 cases, in all of which but 31 
the lesion was in the left anterior lobe. Why the left side is the seat, 
especially when embolism or thrombosis is the cause, has already been 
explained by the fact that the left middle cerebral artery is that which 
is in the most direct line from the heart. The next link in the chain, 
which is 4he question of valvular disease, and its connection with loss of 
speech, has been discovered by H. Jackson, who has found that valvular 
disease is nearly always associated with the hemiplegia, that is, connected 
with loss of speech. He has seen more than 50 of these cases. 

The records of cases of right hemiplegia with aphasia in which I 
made autopsies, show that there were other lesions, but always some 
trouble in the course of the middle cerebral artery. I therefore 
agree fully with the majority of observers, that loss of speech de- 
pends, except in rare instances, upon lesions in the left hemisphere, but 
that it may also follow a lesion in the other hemisphere. Both Brown- 
Sequard and Van der Kolk have advanced theories — the first, that articu- 
late speech is a refiex process ; and the latter, that it is seated in the oli- 
vary bodies. This last view was held by Willis, Solly, and others. Lay- 
cock is of opinion that these organs are " subservient to the emotions 
through the muscles of the face and tongue by language, and emotional 
cries and sounds." And he says: "It is by no means improbable, how- 
ever, that the emotional movements of the hands, as well as of the tongue 
and face, are likewise under their direction. They are, therefore, to be 
considered as regulative ganglia to the motor centres of the facial, hypo- 
glossal, and limb nerves in the medulla oblongata belonging to the sub- 
strata of the sensory tract." 

Dr. Herbert Major, ^ in a very complete article upon the micro- 

^ W. Eiding Keports, vol. ii., p. 284. 
^ West Kiding Reports, vol. vi. 1. 



192 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

scopical anatomy of the island of Keil, sums up his conclusions as 
follows : — 

" 1. The cortical layers of the insula agree in number, order, and gen- 
eral arrangement with those of the vertex, but the cells of the third layer 
are in the insula generally smaller than at the vertex. The vessels and 
neuroglia present no peculiarity. 

" 2. The various gyri forming the insula present a similar structure. 

" 8. No difference of structure can be detected in the right as com- 
pared with the left insula. 

" 4. The method of union of the white matter with the cortex is in the 
insula similar to that observed in other lobes." 

The departure from the healthy state is seen in enlarged vessels, a 
shrunken appearance of the cells of the first layer and a diminution in 
their number, together with even a change in the cell-contents, the nuclei 
being broken down and agglomerated at the centre. The cells of the 
second and third layers have lost their processes, and the protoplasm con- 
tains granular debris, while the other cells of the lowermost layers suffer 
the same changes as well as transposition. 

Aphasia may be dependent upon any form of brain disease which pro- 
duces disorganization of, or pressure upon, the third frontal convolution 
or parts immediately adjacent or of certain cortical centers behind the 
fissure of Rolando.^ Among the common diseases which lead to the 
structural changes are cerebral hemorrhage, thrombosis or embolism, 
tumor, or sclerosis, as well as certain forms of meningitis. Age appears 
to play but a small part in the production of this condition, except so far 
as it influences cerebral hemorrhage, embolism, or the other diseases just 
mentioned. 

Since the appearance of the first edition of this book the study of 
aphasia has received fresh impetus as a result of the development of 
our knowledge of cerebral localization. The observations of Munk^ have 
materially altered the views of physiologists, and the recent writings of 
Kussmaul, Bastian, Broadbent and others, have established the existence 
of the cerebral cortical centers^ which play a part in asemasia and one of 
great importance. 

Bastian^ has formulated the ideas of modern writers as follows : — 

I. Defects of verbal memory; that is defects in the association of ideal 
things or of conceptions with ideal words. 



^ Among fifteen cases reported by Sander* there were two in which the original 
lesion was found in the left parietal lobe, in some of the bundles of fibres radiating 
from the corpus striatum. 

^ Ueber die Functionen der Gehirnsrinde. 

•^ The Brain as an organ of Mind, 1880. 



* Archiv fiir Psychiatric, ii, 38. 



ASEMASIA. 193 

A. AMNESIA VERBALE. 

(a. Paralytic variety ; b. Incoordinate variety.) 

1. Diminished Excitability of the Auditory Word-Centres. 

2. Defective Action of the Visual Word-Centres. 

3. Damage to Visual Word-Centres and of Afferent Fibers to Auditory 
Centres; together with certain defects producing Incoordinate Amnesia. 

4. Damage to commissures between Auditory and Visual Word-Centres. 
II. Defects in the association of Ideal Words with verbal movements 

for speech and writing, or for either of them singly. 

B. APHASIA. 

5. Damage to first parts of outgoing tracts leading from Cerebral 
Word-Centres to left Corpus Striatum. 

0. AGRAPHIA. 

6. Damage to first parts of outgoing tracts leading from the left Visual 
Word-Centre. 

D. APHEMIA. 

7. Damage (a) to first parts of outgoing tract leading from the left 
Auditory Word-centre, or (6) to some lower part of the same tract, or 
(c) to the actual Motor Centres for articulation. 

The involvement of the visual and auditory centres as has been stated, 
even though there may be no disease of the island of Reil, accounts for 
the production of the various forms of asemasia. In well reported recent 
cases the matter has been definitely settled that destruction of one or 
both of these centres, may be followed by disruption of the corrective in- 
fluence of visual or auditory associations. The individual may be unable 
to speak or write upon dictation, or he may be equally powerless to 
copy a printed page or correctly count a given number of objects or 
figures. The case of the late Dr. Allin, of New York, which has been 
ably reported by Dr. A. B. Ball, is one of the most valuable contribu- 
tions to the modern literature of aphasia. In Dr. Allin's case the lesion 
was confined to the " whole of the inferior parietal lobule and the first 
temporal gyri," and no change in the Island of Reil was found. Dr. 
Allin visited my office some months before his death, and at various 
times had been seen by Drs. Ball, Seguin and Metcalfe. 

The feature of his asemasia, was his inability to use common nouns and 
proper names. He was able usually to closely approach in sound the 
word he desired to use, but if he saw the initial or heard the first syllable, 
he was able to finish the rest. At first he was unable to repeat the word 
after it had been pronounced by another person, but subsequently learned a 
large number of words used in ordinary conversation. He was agraphic, 
and could not write at dictation though he recognized the number of 
letters and made them by straight lines. He was utterly unable to com- 
prehend auditory symbols. Dr. Ball said to him, " Dr. Peters called to 
see you;" he replied, " I don't know him." The name was repeated to 
13 



194 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

him several times, but he failed to recognize it, although it was the name 
of an intimate friend. The written name was then shown him ; " What a 
fool I am," he exclaimed, " of course I know him." He afterwards said, 
" The words I can't pronounce are the words I can't hear." This indi- 
cated a disruption of the auditory control. Dr. Allin could sing, gesticu- 
late, but manifested a peculiar symptom — the reversal of the position of 
objects he took up. For example, he placed his knife and fork with 
their points toward him upon the table, but he immediately recognized 
his mistake. When he read aloud he seemed to have lost the guiding 
control of the ear, for he often used the wrong word. 

The failure of the visual and auditory centres gives rise to many inter- 
esting phases of hindered speech action and writing power. Bastian il- 
lustrates the table I have just given by several groups of cases of which 
the following are examples : — 

1. An individual who could articulate distinctly any words that 
occurred to him either spontaneously or when they were pronounced 
slowly and loudly, but could not speak at other times. He could read 
aloud from printed copy, but could not repeat the words he had seen the 
moment before. Here was a case in which the auditory centre was needed 
and when words were not properly revived by volitional excitation. 

2. An individual who could repeat spoken words but could not read 
aloud. 

3. Dr. Banks' case of the man who had lost the power of apprehend- 
ing what was spoken by others with loss of comprehension of written or 
printed characters. 

The explanation of word blindness recently given by Magnan^ bears 
out the investigation of Terrier and Tamburini. Magnan considers that 
there are two centers which are involved ; the visual perception goes 
first to the corpora geniculata or some other center in their neighborhood 
(see Charcot's plate,) and from them to the angular gyrus, where it is 
made the basis of psychic action involving an exercise of memory and 
reasoning power. The disruption of this center with the island of Eeil, 
eventuates in the phenomenon of word blindness, as the idea cannot form 
expression. Two cases have been presented by him. 

Very few examples of aphasia in very young persons have been re- 
ported, for vascular neuroses are quite unusual among children, and right 
hemiplegia, with a lesion in this particular part of the brain, is of rare 
occurrence. A case was reported by Eulenburg which was quite unique.'' 
The patient was eight years old ; two years before he had had scarlet 
fever, and six weeks after the development of the disease there were con- 
vulsions and coma, followed by right hemiplegia with aphasia. The pa- 
ralysis almost subsided in two weeks. He speaks but two words, viz. : 
" Ach," which he always uses for " mien," and " Ja," with which he an- 
swers all other questions. The fact that dropsy and albuminuria had ex- 

1 Gazette des Hdpitaux, Jan. 24, 1880. 

2 Berlin Med. Gesellschaft, July, 1869, 



ASEMASIA. • 195 

isted induced the author to infer the presence of softening of the central 
organ of speech. 

Aphasia of a temporary character may depend upon functional condi- 
tions, such as cerebral congestion, indigestion, or as the result of fright 
or other emotional forms of excitement, or may be connected with epilepsy 
or hysteria. Kisch^ reports three cases of transitory aphasia due un- 
doubtedly to cerebral congestion. One of these was a very stout woman 
who, having drank a very large quantity of carbonic acid water, fell to 
the floor after being dizzy, but did not lose consciousness. This seizure 
was followed by headache, and later by complete aphasia. She subse- 
quently recovered. Two cases of aphasia of a similar character are re- 
ported by Berger.' 

Habershon^ presents an example of aphasia which was caused by fright. 
A much more rare variety of the disease is that which is connected with 
epilepsy. Three such cases were published by Allbutt.* One of these 
patients fell, striking on his left temple ; some time afterwards epilepti- 
form attacks appeared with paralysis of the right arm and leg. The 
second case was that of a woman aged fifty, who had had epileptic con- 
vulsions of a bilateral character for two years. After the attack she was 
somewhat aphasic, and " had a mental vision of the words," but was un- 
able to speak them. This condition of affairs lasted for two hours. The 
third patient was a man, thirty years of age ; there was no loss of con- 
sciousness, but attacks of hyperaesthesia in the right arm and hand, fol- 
lowed by blindness, lasted for twenty minutes or longer, and were suc- 
ceeded by speechlessness lasting two hours. 

Diagnosis. — In making the distinction between aphasia and other 
difficulties of speech, we are apt to be misled by defects in articulation, 
dependent upon inco-ordination or paralysis of the tongue, or by certain 
mental irregularities, or sometimes by congenital mutism.^ We are to bear 
in mind the fact, that there may be transitory aphasia, but that organic 
disease of the speech-centre is generally of permanent duration ; and that 
there are but very few exceptions to this rule. The speech defects which 
are of a local character are symptomatized by the patient's inability to 
speak at all, though he may fully convince us of his ability to form words 
and appreciate their meaning ; and, moreover, he can always, should there 

1 Berliner Klin. Woohenschrift, 1869, 433. 

2 Wien. Med. Woch., 1869, 102. 

^ London Lancet, 1870, vol. ii. 402. 

* Med. Times and Gazette, 1869, vol. i. p. 491. 

^ Dr. Browne,* of the West Riding Asylum, recently examined 29 cases of morbid 
affections of language, or all in the existing population of the Crichton Institution 
at Dumfries ; 14 of these were females, and 15 males. Of these, which he arranged 
in three classes, he found among the women : " 1. Intermittent mutism 5, in one con- 
nected with the catamenia. 2. Constant mutism, 7 : of these one had been a public 
singer; 1 when roused could with difficulty articulate, having facial paralysis; 1 



* Op. cit. p. 297. 



196 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

not be paralysis of the hand or forearm, write any word that he may wish 
to speak. This is not the case in aphasia. In lighter forms of tongue 
paralysis there is no trouble about the selection of words, but simply a 
clumsiness in pronoun ciation, and in many of these forms evidences of 
local muscular weakness, in connection with the speaking apparatus, draw 
attention to the real nature of the trouble. A disease presenting these 
local defects is a so-called glosso-pharyngeal paralysis. The same condi- 
tion of affairs is met with in general paralysis of the insane, but with this, 
as well as other troubles of the same kind, there are various other symp- 
toms which accompany the speech defect, such as mental impairment, 
with peculiar delusions and muscular trembling. Hysteria sometimes 
gives rise to a very curious speech derangement, which, in its strictest 
sense, can hardly be called aphasia. The patient occasionally introduces 
obscene and profane words in place of others more conventional. A form 
of speech trouble described by Winslow^ and Romberg^ is expressed by 
mimicry of individuals, who speak to the patient or who talk within ear- 
shot. He closely imitates the tones of their voices and mannerisms, and 
repeats the words addressed to him, besides mimicking their gestures and 
attitudes. These phenomena are occasionally seen among the insane. 
Romberg has called this morbid state echolalia. I have at present a case 
under observation who is an example of this kind, only his infirmity does 
not exist to so marked a degree as in the cases of the two observers above 
mentioned. My patient is an idiot, and possesses but very little mental 
power. He can point to his mouth, places his hand upon his abdomen 
when hungry, and can call attention to his bodily needs by equally simple 
gestures, but beyond this he is more an automaton than a living being. 
When asked a question, for instance, " How are you ? " he repeats the 
two last words, "Are you?" and " Why don't you answer? " he replies, 
"Don't you answer?'' He invariably repeats the last two or three words 



could not walk in consequence of spinal deformity ; 1 was an idiot laboring under 
phthisis; 1 uttered cries when suffering pain. 3. One was reduced to monosyllabic 
utterances. 4. One manifested incessantly, day and night, irresistible loquacity. 

Among the males: "Intermittent mutism, 1. 2. Constant mutism, 5: in 1 the 
mutism is of 20 years' duration ; in 1 it is accompanied by tremor of the limbs ; in a 
third, who attempted to cut his throat, there is unintelligible muttering soliloquy. 3. 
One was reduced to monosyllabic utterances. 4. Two manifested constant loquacity: 
in one, an idiot, there is congenital left hemiplegia ; in the other, who is healthy, the 
loquacity is so great and rapid that the words run into each other so that he seems to 
speak in long sentences. 5. Two present symptoms of general paralysis ; the articu- 
lation is indistinct or unintelligible. 6. In one case there appeared to be the omis- 
sion of the first syllable of every word, followed by alternate mutism and loquacity. 
7. In one, an idiot, language is limited to a few words, and these are exclusively 
oaths, with congenital right hemiplegia, and club-foot. 8. Two idiots emit nothing 
but acute inarticulate cries ; one roars like a wild beast." There was no paralysis in 
these cases except of the face in two general paralytics, and of the lower extremities 
in two idiots, the paralysis in these latter cases being congenital. 

1 Obscure Diseases of the Brain and Mind, Am. ed. p. 343. 

^ A Manual of the Nervous Diseases of Man, Syd. Trans., vol. ii. p. 431. 



ASEMASIA. 197 

of any question that may be put to him, so that his answers are but echoes 
of the questions. Such a defect is explained by Bastian by the fact that 
"the auditory word centres respond only to direct 'sensory' incitations, 
and not at all to those of the ' associational ' or * volitional ' types." 

In the early speech disturbances of left hemiplegia, or organic diseases 
of the brain, the patient's attempts to articulate will result in a clumsy 
and mispronounced word ; while in aphasia his articulation, be it ever so 
limited, is rarely imperfect, his " yes " or " no " being fairly pronounced, 
or, if he has improved so far as to be able to pronounce but a part of a 
word, he will do this distinctly, while perhaps the other syllables will 
either be not pronounced at all, or in such a way as to be utterly unintel- 
ligible. There are generally with the aphasic great impatience and em- 
barrassment, mimicry, and gesticulation, which are evidences of mortifi- 
cation arising from the knowledge of his failing, and his gestures take 
the place of words. In agraphia the handwriting or results of attempts 
at writing must be compared with specimens, such as would be made by 
patients who are insane, ataxic, or paralyzed, and it is necessary for us to 
carefully note the omission of words, or combination of syllables which 
bear no relation to one another, as well as the character of the patient's 
composition. If he be insane, he will not admit any absurdities to which 
he may give expression, but with the aphasic the case is different, for he 
always evinces his chagrin when he finds that he has written the wrong 
word, and endeavors to correct his mistakes. There are cases spoken of 
by Bacon ^ and others, in which the only evidence of the patient's insanity 
is his writing, but even here the defect is more in the expression of a dis- 
ordered mental state than in an impairment of the communicating faculty. 
The handwriting of the general paralytic sometimes closely resembles 
that of the aphasic patient, but in the first, with time there is progressive 
impairment, while in the other, if anythi-jg, there is improvement. 

The medico-legal questions which may arise in regard to the responsi- 
bility of aphasia are worthy of consideration. The aphasic of course 
may suffer an intellectual impairment, which lasts a short time after the 
attack. This is not necessarily accompanied by a loss of judgment. It 
is more a condition of mental sluggishness, and it will not do to say that 
the individual is incompetent. The aphasic makes intelligent efforts to 
communicate, even though he may not be able to do so. He gesticulates, 
and tries to explain himself, and the expression even of his eyes tells of 
everything but intellectual unsoundness. Additional evidence of soften- 
ing in dementia throws an entirely different light upon the matter, but 
even then it must be remembered that aphasia is not necessarily associated 
with such states. 

A case of interest is reported by M. Lucas Championnieres : ^ " The 
question was raised in this particular instance a propos of a case in 
which the patient, in spite of an enfeebled intelligence, had become ca- 

1 On the Writing of the Insane, p. 12. 

2 .Journal de Med. et de Chir. Prat., abst. Br. Med. Journ. Sept. 15, 1877. 



198 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

pable of writing -with the other hand. He could not, however, write if 
left to himself, and could only recopy what was written and set before 
him, and the expert physicians vainly tried to make him recopy a power 
of attorney or a will, while he willingly wrote any ordinary phrase or 
document which did not bind him to anything. This man, then, knew 
perfectly what he was doing, and the Societe de Medecine Legale con- 
cluded that he possessed still thorough intelligence and free will to be 
able to continue to enjoy his civil rights, the intellectual debility which 
he had suffered not appearing to be sufficient to justify what the 
French laws call an ' interdiction.' " The society recommended that 
he should be taken care of by a " council," so that he should be guar- 
anteed protection against danger that might arise in the condition of his 
affairs. 

We must bear in mind the existence of heart trouble should it exist, 
or vegetations and other indications of extraneous disease which might 
lead to the causation of thrombosis or embolism. 

In regard to the diagnosis of aphasia it may be said upon the autho- 
rity of Seguin that " predominant word deafness or word blindness, with 
hemiansesthesia, cutaneous, muscular or sensorial, is dependent upon a 
lesion placed behind the fissure of Kolando in regions which correspond 
with the sensory cortical centres." 

Prognosis. — The view we are to take of our patient's condition is to 
be governed entirely by the question whether there is or not a primary 
organic disease, its importance and the character of the aphasia.^ In 
the light forms, such as result from fright and cerebral congestion, or 
those connected with hysteria, the prognosis is exceedingly good, and the 
same is the case when it is the result of protracted fever. Legroux 
(op. cit. p. 60) speaks of an aphasia of quite temporary duration, which 
is occasionally of gouty origin, or connected with diabetes or 
albuminuria. ^ Dr. Rotch has also described varieties of tempory aphasia 
met with in patients who are the subjects of Bright's disease, and presents 
two cases. The prognosis of the condition itself is quite good, but a 
serious indication of grave cerebral trouble. Aphasia with paralysis is 
always significant of deep trouble. Such an aphasia, when it occurs 
with hemiplegia, may persist perhaps during the individual's lifetime, 
and after every vestige of the hemiplegia has disappeared. If there 
be softening, or previous acute cerebral disease, or if there be evidence 
of arterial degeneration, or valvular deposits, the case assumes a hope- 
less aspect, and may be nearly always pronounced incurable. Aphasia 
as the result of traumatism is occasionally relieved by surgical interfer- 
ence. 



^ In one case reported by Baternan, the patient recovered almost entirely, and he 
could pronounce every word distinctly, with the exception of those containing the 
letter P. 

2 Boston Medical and Surgical Journal, May 26, 1881. 



CEREBRAL SCLEROSIS. 199 

Treatment. — Our first indication is to improve, if possible, the or- 
ganic disease, and sometimes we are able to better the patient's condi- 
tion to a great degree. Should there be hemiplegia, contractures, or 
other evidences suggestive of degeneration of the cerebral tissue, we will 
find ourselves powerless to help our patient materially. It is only when 
aphasia exists as an isolated symptom that very active measures are fol- 
lowed by some show of success. In such a case local blood-letting, 
purgation, and the use of ergot, and the bromides, may completely relieve 
the condition; and even when the disease is established, and the de- 
struction of the speech centre has been limited, there is a possibility of 
improving the patient's partially lost faculty. Systematic education, 
and the training of the left hand, and the development of the right side of 
the brain, may result in au increase in the patient's faculty of communi- 
cating. In rare cases, viz., those of traumatic origin, it may do well to 
use the trephine. Broca, under the heading, " La Topographic Cranio- 
Cerebrale," ^ described experiments made by him to determine the 
relation of the cranial bones with underlying parts ; and Turner '^ has 
made additional observations, and given rules for determining this rela- 
tion. 

CEREBKAL SCLEROSIS. 

Synonyms. — Sclerencephalia ; atrophia cerebri. Tabes cerebri. 
Atrophy of the brain. 

Definition. — An induration of the nervous substance, consisting in 
increase of connective tissue, and atrophy and destruction of the nervous 
elements, constitutes the condition known generally as sclerosis. The 
French writers have applied the terms '' Sclerose en plaques disseminee," 
" rubanee," " peripheriques," and " diffus " to the disease ; adopting these 
names in regard to the character, site, and form of the lesion. Such ex- 
pressions, while making the nomenclature more exact, imply delicate 
distinctions which are not always to be made, and do very well only when 
applied to appearances witnessed after death, but are not so valuable 
when making a diagnosis before death. I prefer to use the terms " dif- 
fused sclerosis" of the brain, " cerebro-spinal sclerosis," and "spinal 
sclerosis." Even this nomenclature is open to objection, for it is very 
rare for sclerosis of any kind to be confined to either the brain or cord, 
though such involvement of the organ not originally affected may be of 
late date. To confirm this statement I may allude to the ocular symp- 
toms which characterize the early manifestations of posterior spinal 
sclerosis, or the locomotory defects that are to be seen in some sclerosed 
conditions supposed to be peculiarly cerebral. I may furthermore add 
that in all forms of sclerosis there are generally points of induration 
found after death in both brain and cord. Nevertheless, it is important 

1 Kevue d' Anthropologie, tome v. No. 2, 1876. 

^ Journal of Anatomy and Physiology, vols xii, xiv, 1873, 1874. 



200 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

for US to make distinctions in the manner and origin, course and termina- 
tion of the various forms of the disease, and we must therefore be con- 
tented with an anatomical division. 

DIFFUSED CEREBRAL SCLEROSIS. 

The older writers were in the habit of giving the title " atrophy of the 
brain " to a condition of that organ which was undoubtedly that which 
we are now discussing. It is probably one of the most imperfectly un- 
derstood nervous diseases, and in many instances the diagnosis cannot be 
made during life. 

Symptoms. — The cerebral condition, which is tardy induration of 
an unlimited region, and does not consist in scattered deposits, is a slowly 
developed morbid state, and is expressed by a train of rather obscure 
symptoms, the most striking of which are contractions and epileptiform 
convulsions, impairment of mental power, and various affections of 
speech. In some cases the conditions date from infancy, and the charac- 
teristic feature is want of development of the extremities. In others, a 
condition of imbecility exists, in which the patient leads almost a vegeta- 
tive life. One case (No. II.), which I shall relate, was of this kind. 
Her last years of life were spent in bed, and for a long time there were 
dementia and unconscious discharges from the bladder and bowels. Some 
of these cases begin later in life, and the first indications may be either 
tremor or an epileptiform convulsion, and subsequently various disturb- 
ances of motility, such, for instance, as spastic contraction of the muscles 
of the arm and leg, and the fingers become twisted, deformed, and distorted 
so as to be useless. Tremor is not rare, and as the disease advances there 
may be various other symptoms, such as paralysis and muscular atrophy, 
as well as glosso-labial paralysis. Psychical disturbances are early symp- 
toms, and a species of dementia is rapidly produced. 

Case I. — Mary J., the patient, a girl 14 years old, was brought to me 
during the month of September, 1871. She had been very ill some six 
years before, and from what I learned from the mother, the attack of 
illness must have been scarlatina, or some other eruptive fever. Her 
convalescence was slow, and attended by convulsions of an epileptoid 
character. She slept much of the time, and seemed dull and stupid. 
Her memory became impaired, so that her mother was obliged to take 
her from school, and when allowed to play she quarrelled with the child- 
ren in the neighborhood, and became so warlike that it was found neces- 
sary to keep her at home. When she had suffered for over a year in 
this way, she began to lose her power of speech, and when she attempted 
to converse with those who spoke to her she talked in an unintelligible 
manner; the tongue "seemed to be paralyzed." In 1868 her arms be- 
came very weak, and trembling grew violent when she made any manual 
effort. This loss of power, which was observed more in the right arm, 
became so great that she was unable to use it in any way whatever. 
After a year or so the arm became rigid and atrophic, and within twelve 
months the other arm followed. She is now in a condition of imbecility. 
She holds her head very far forward when she walks, her chin being 



CEREBRAL SCLEROSIS. 201 

raised. The right pupil is slightly larger than the left. There is 
ataxic loss of speech, the tongue being entirely out of control, but 
nevertheless she incessantly tries to talk. Her senses are but slightly 
impaired, and it may be said she hears well, if we can place any re- 
liance upon the rough tests I made, such as speaking to her behind her 
back. Her sensibility to pain is not apparently lost, for she gives ex- 
pression to signs of suffering when she is pinched, but she complains of 
dyssesthesia. 

Her right arm, forearm, and hand are semiflexed and rigid, and the 
atrophy of the palmar muscles suggests the " main en griffe." Her nails 
are long and thick, and the skin not only of this hand, but that covering 
the hand and arm of the other side, is blue and cold. The flexors carpi 
radialis, palmaris longus, pronator radii teres, and other muscles upon the 
anterior aspect of the forearm were atrophied and contracted, as well as 
the extensores communis and minimi digiti. This appearance was found 
on both sides, but more so on the right. When she makes any voluntary 
movement, the tremor occurs, and it is like that which marks other 
forms of this disease ; that is to say, it is increased by persistence in the 
attempt. The arms are the only parts affected by the tremor. Her con- 
vulsions occur about twice a week. 

Case II. — M. S., aged 18 years, admitted to hospital June 21, 1873. 
When the patient was fifteen months of age she had her first epileptic con- 
vulsions. These, according to her stepmother, have gradually increased 
in number. At ten years of age she became paralyzed. The paralysis 
affected her right side, and came on gradually, without loss of conscious- 
ness ; and it has increased so that at present all the muscles of the extre- 
mities, and some of those of the face, are paralyzed. Sensibility is not 
affected. She has imperfect control of the voluntary muscles, and does 
not use them readily ; and when spoken to does not appear to appreciate 
what is desired immediately. 

Dynamometer : left side 15, right side 19. 

The sesthesiometer was not used, as the patient was too much demented 
to appreciate what was wanted. 

Her head is very large, the patient being of ordinary stature. The 
saliva flows continually from the corner of her mouth, and her com- 
plexion is dusky and bad. The muscles are all more or less atrophied. 
Heart and lungs are normal ; no murmurs other than the venous hum of 
anaemia. 

The patient came under my care in June, 1876. She was then in a 
condition of profound dementia. She had been in bed for some 
months, and when I examined her I found her conditions to be the fol- 
lowing : — 

There were no constant ocular defects, no ocular paralysis, and the 
pupils responded well ; but there had been occasional attacks of uncon- 
sciousness, attended by nystagmus, when her eyeballs would move from 
left to right. There was slight paralysis of the buccal muscles, and the 
mouth was almost constantly open ; while a profuse secretion of saliva 
drooled from the angle of the mouth and over her undergarments and 
bed-clothes. Her mouth contained partially masticated food, of which 
there was an accumulation between her teeth and cheeks on either side. 
Her teeth were very filthy, and the gums tender and bleeding. No 
appreciative facial paralysis was detected. When spoken to she smiled 
in an inane manner, but did not attempt to speak. She was occasionally 



202 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

very apt to cry for several hours at a time, and seerniagly without cause. 
Her position in bed was an exceedingly uncomfortable one ; she usually 
reclined upon her left side, the head drawn down to the same side ; and 
it was agitated by coarse tremors, which ceased when she slept. Her 
right arm and forearm were drawn to her chest, and likewise agitated by 
almost constant tremors. Her left arm was also adducted, and the fore- 
arm semi-flexed ; while the fingers were extended. Tremors of the same 
character agitated this member. The thighs and legs were drawn up, 
but did not seem to be quite so rigid as the arms, and there was great 
atrophy of all four extremities. She passed her excreta unconsciously, 
and a bedsore had formed upon the left buttock. Voluntary power 
was absent almost entirely, and I do not remember having seen her 
change her position in bed from the time I first saw her until her death. 
Sensibility to pain was very much lost, and reflex excitability was nil. 
Perhaps some of this want of sensibility was due to the horny condition 
of the plantar skin. She had a great many general convulsions, attended 
by turgescence of the surface vessels, and nystagmus. She continued in 
this condition during the year, improving slightly during this time in 
regard to the number and violence of convulsions, but gradually growing 
weaker. 

Dec. 26, 1876, 1.30 P. M. Being fed with stewed meat she had three 
convulsions in rapid succession, while her mouth was filled with food. 
Attendant states that she first became cyanotic, but her teeth were so 
clenched that the nurse was unable to extract the food. As soon as the 
spasms relaxed, she thrust her fingers in the mouth of the patient, and 
removed a piece of meat, but the patient was dead. 

Autopsy 18 hours after death. — No food found in larynx or fauces. 
Membrane of brain congested and thickened ; the gray matter of all 
the convolutions was of the consistency of the white of a hard-boiled 

I afterwards carefully examined the brain, and found patches of ad- 
vanced sclerosed tissue over the coitex, and throughout the gray and 
white matter of other parts of the hemispheres. The induration was so 
general that the brain seemed, as a whole, quite hard and tough. The 
arteries were diseased throughout, and the calibre of the vessels was 
quite reduced. 

Case HI. — This patient presents evidences of cerebral sclerosis, which 
were evidently of very early origin. The patient is at present in the 
Epileptic and Paralytic Hospital. Her early history is somewhat meagre. 
She gives a history of epilepsy, and has attacks several times a week. 
Her mind is very feeble, and she has attempted suicide several times. 
The atrophy is one-sided, and there is probably atrophy of the left side of 
the brain. The following history and table of measurements were fur- 
nished by my predecessor. Dr. Janeway : — 

E. B., aged 19 years; state single. Admitted to hospital May 1, 1868. 

Examination. — Head : no facial paralysis or deviation of tongue ; no 
atrophy of tongue ; pupils normal, no strabismus ; hearing good, as is also 
common sensibility. Pight upper extremity : shoulder-joint is freely 
movable; elbow cannot be fully extended ; hand flexed and extremely 
pronated ; muscles of hand to a certain degree rigid ; fingers flexed, 
thumb not rigid ; marked atrophy of entire arm; skin of fingers soft and 
sodden, but no other changes of nutrition. 

Measurements. — Middle sternal notch to coracoid process : right side. 



CEREBRAL SCLEROSIS. 203 

4i inches ; left side, 4| inches. Edge of acromion to external condyle ; 
right side, lOi inches; left side, IO2 inches. External condyle to styloid 
process of ulna: right side, 7 J inches; left side, 8? inches. Apex of 
acromion to styloid process : right side, 7i inches ; left side, 8 inches. 

1st metacarpal bone (index finger) : right side, 50 mm. ; left side, 55 
mm. Metacarpal bone (little finger) : right side, 47 mm. ; left side, 50 
mm. Metacarpal (thumb) : right side, 40 mm. ; left side, 43 mm. ; right 
index, 65 mm. ; left index, 70 mm. Little finger: right side, 53 mm.; 
left side, 60 mm. 

Thenar eminence, thickness of: right, 31 mm.; left, 35 mm. Hypo- 
thenar eminence, thickness of: right, 20 mm. ; left, 24 mm. 

Vertebral prominence to edge of acromion : right side, 61 inches ; left 
side, 78- inches. Inner edge scapula to supra-spinal notch, to deltoid : 
right side, 121 inches; left side, 14| inches. Length inner border sca- 
pula : right, 51 inches ; left, 5^ inches. 

Semi-circumference thorax (4th rib): right, 13^ inches; left, 14i 
inches. 

Sensibility of right hand normal in every respect. Dynamometer : first 
trial in left hand, 18 ; second trial, 10. Hardly any power of right hand, 
but reflex movements are readily excited in it. Circumference : right 
arm, 8J inches ; right forearm, 8^ inches ; left arm, 9^ inches ; left fore- 
arm, 91 inches. 

Lower extremities : left, length of fibula, I3i inches; right, length of 
fibula, 13t inches; right calf, Hi inches; left calf, 12| inches. Lower 
edge patella to lower edge external malleolus: right, 131 inches ; left, 
131 inches. Anterior edge inner malleolus to end of great metatarsal : 
right, 4i inches ; left, 4 J inches. Circumference over heads of metatarsal 
bones : on right side, 7^ inches ; on left side, 71 inches. Anterior sup. 
spinous process to lower malleolus : right, 281 inches ; left. 281 inches. 
Supra-sternal notch to lower edge of external malleolus : right, 45* in- 
ches ; left, 481 inches. 

Sensibility of legs good in all respects. Difierence of malleoli as she 
lies in bed, i inch. 

Causes. — So little is known in regard to the circumstances favoring 
the development of this disease, that beyond the mention of certain facts 
of age and sex nothing more can be said in connection with etiology. 
Women seem to be more affected than males, and we may consider that 
it is usually a condition that begins in infancy and progresses slowly, or 
is arrested ; or, on the other hand, it may begin in advanced life, and 
progress more rapidly. In one case which I have seen, syphilis had proba- 
bly something to do with its development. Scarlet fever or acute diseases 
of the brain are apt sometimes to leave behind a certain amount of 
induration. 

Morbid Anatomy. — Those authors who have made autopsies have 
found a condition of density of the white matter, the same being shrunken 
and more firm at the centre of the hemisphere than at the periphery. 
When a microscopical examination is made, the brain-tissues are found to 
show appearances which are highly characteristic. The connective tissue 
will be found to be proliferated, and to present a fibrillated appearance. 
Corpora amylacea are often present, and we usually find granular deposits 



204 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

in the blastema. The new tubes are quite changed in character, and are 
shrunken and attenuated. The axis cylinder may have disappeared, and 
its place may be filled by a granular substance. The nerve-cells are 
greatly altered, their prolongations being torn off, and their contents 
granular. Oil-globules are often found scattered over the field, and some- 
times collected about the blood vessels. These vessels are generally much 
increased in size, and their walls are thickened, and covered by a granu- 
lar deposit. If the gray matter be the part affected, we shall find an un- 
usual development in the blood vessels. 

I have spoken of the involvement of the cranial nerves. It is not un- 
common to find at the roots of this nerve a sclerosed point which has 
involved the nuclei. 

Diagnosis. — Diffused sclerosis, in its incipiency, may be mistaken for 
cerebral softening, but though the two diseases seem very much alike, the 
absence of severe pain, and variations of temperature in the latter, as well 
as subsequent progress of the disease, will enable us to decide ; it must be 
borne in mind, however, that in the great number of cases diffused sclero- 
sis begins in very early life. The congenital cerebral non-development 
which we sometimes see will be recognized by the absence of tremor, but 
we must not confuse such cases with those of early intracranial disease 
where spastic paralysis and increased tendon reflex are conspicuous. 

Prognosis and Treatment. — The former is excessively bad, and 
even temporary relief, I think, is out of the question in the great majority 
of cases. I have never seen a case cured ; and if there is any disease of 
the nervous system that is utterly beyond the reach of drugs, I am con- 
fident that it is this. The actual cautery has been used, but, as far as I 
can learn, without benefit. The treatment of individual symptoms may 
greatly increase the comfort of the patient, and with this object hyoscya- 
mine in doses of from gr. iJo to gr. 25 may be given to quiet the tremor or 
spasm. For the convulsions the free use of ergot does good, while as rou- 
tine treatment it is advisable to administer the salts of silver or mercury. 



BRAIN TUMORS. 205 



CHAPTER VI. 

DISEASES OF THE CEREBRUM AND CEREBELLUM. 

(Continued). 

BRAIN TUMORS. 

When the brain chances to be the seat of a morbid growth, whether 
vascular, or parasitic ; homologous, or heterologous, we may be apprised of 
the existence of such a new formation by a train of symptoms which 
have no very constant character ; or the tumor may even involve a large 
part of the brain without giving rise to any indications of its presence 
during the life of the patient. There is no regularity as to the grouping 
or appearance of symptoms, although the very valuable researches of 
Hughlings Jackson have enabled us to define the position of the morbid 
intracranial growths with much greater certainty than heretofore. 

Symptoms. — We may group the prominent symptoms under the 
following heads : — 

1. Convulsions. 

2. Vomiting and vertigo. 

3. Headache and cutaneous hypersesthesia or ansesthesia. 

4. Hemiplegia. 

5. Paralysis of cranial nerves. 

6. Ocular symptoms. 

7. Psychical disturbances. 

Convulsions. — The appearance of convulsions as the only indication of 
brain tumors has frequently led the observer to make a diagnosis of epi- 
lepsy However, when it is taken into account that there is, at the 
most, but transitory loss of consciousness — and even this is very rare — 
during the epileptiform attack, such a mistake is hardly possible. The 
convulsions may be general or local, and in this place it is proper to 
refer to the connection between certain cortical lesions produced by brain 
tumors and consequent convulsions beginning in members which are sup- 
posed to have motor centres. Among sixteen cases collected by Hugh- 
lings Jackson there were several in which the convulsive seizure began in 
the thumb of one hand, and finally became general. Cortical lesions 
were found in the third frontal convolution. In another the epileptiform 
seizure began in the right cheek, and still another is reported where the 
right arm was the point of seizure, with subsequent paralysis ; and after 
death a tumor was found in the uppermost frontal convolution on the 
opposite side. Upon the authority of Bastian ^ and Reynolds, " it may 

1 Op. cit., p. 493. 



206 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

be stated that convulsioDS are most common when the disease is situated 
in the posterior lobes of the brain or in the cerebellum, and least fre- 
quent when the anterior lobes are affected." This statement must be 
considered to apply, however, mostly to those cases presenting general 
convulsion. Local spasms, which may even be followed by general con- 
vulsion, begia in the limb innervated by a psychomotor centre, and are 
significant diagnostic signs. 

Hughlings Jackson considers that psychical disturbances are likewise 
connected with destruction or injury of the posterior lobes. When the 
growth is syphilitic, the presence of much headache before the convul- 
sion is the rule. Convulsions may be the first symptoms of tumor, and 
when they occur in advanced life there is always occasion for suspicion. 
Several writers Have agreed that convulsions and other symptoms are the 
result of irritation of parts adjacent to the tumor, and that they may 
vary in appearance and severity in proportion to the local disturbance 
created by the growth ; for this reason convulsions may appear in the 
most irregular manner. Pain is one of the earliest and most persistent 
symptoms. It is nearly always localized, and is very intense, especially 
if the meninges be affected in any way, when it may be combined with 
muscular twitchings. It is rare for it to subside for an extended period, 
and then reappear ; and in such cases it is highly probable that the 
growth has either expanded in some other direction, or that the tissues 
have become accustomed to its presence in the manner suggested by 
Niemeyer. Pain aggravated at night is highly suggestive of a syphilitic 
tumor. 

Photophobia is sometimes a symptom, and intolerance of noise is a 
decided feature, while vertigo is produced by very slight irritation, and it 
has been found in tumors which injure the corpora quadrigemina that 
this occurs when the patient closes his eyes. Such was noticed to be the 
case in an example reported by Dr. Duffin. This patient, a man aged 
twenty-five, presented the following symptoms : A dragging of the mus- 
cles at the back of the neck, so that the head was pulled downwards and 
backwards, unsteady walk, vertigo when eyes were closed, vomiting, fre- 
quently slow and irregular circulation, obscured intelligence, double optic 
neuritis, defective sight, and finally coma. A gliomatous tumor was 
found which had destroyed the pineal gland, and extended into the optic 
thalamus. Reeling is commonly associated with vertigo, and is generally 
symptomatic of a growth in the substance of the cerebellum. Symptoms 
of minor importance are cutaneous anaesthesia or hypersesthesia, with 
tingling or formication of the hands or feet. Such anaesthesia may affect 
the tract supplied by the fifth nerve, while deep cerebral pain may co- 
exist. This combination is almost pathognomonic, and should be looked 
upon with suspicion. Total abolition of cutaneous sensibility in connec- 
tion with cerebral tumors has been studied by ^Ball and Krishaber. Of 

^ Tumeurs Cerebrales art. in Dictionnaire Encyclopedique, p. 456. 



BRAIN TUMORS. 207 

185 cases of cerebral tumor it was found that sensibility was abolished in 
but fifteen instances. In seven others it was simply blunted. 

Hemiplegia is not an uncommon symptom, and may be sudden when 
produced by the rupture of a vessel ; or of gradual origin, as the result of 
pressure made upon important parts of the motor tract by a tumor of 
slow growth. By far the most significant paralyses are those of local 
origin, connected with local spasms, and these usually indicate a lesion in 
the cortical motor zone. Paralysis is generally a late symptom, and 
may begin by loss of power of one member, and afterwards of the other 
of the same side. By far the most interesting paralyses are those of 
the cranial nerves, because of their value as diagnostic signs ; and not 
only may the optic nerve be affected, but the auditory, motor oculi, and 
even the fifth, may suffer an alteration of function. 

Jackson and others are of the opinion that those muscles concerned 
more in the execution of direct voluntary movements are often affected 
in a greater degree than those which perform automatic movements al- 
most exclusively. 

Paralysis of both external recti muscles occurred in one of Jackson's 
cases, and is, perhaps, one of the most significant indications of the pre- 
sence of gummata. Lateral deviation of the eyes from the side of the 
lesion is also a form of cranial nerve paralysis which is by no means a 
rare symptom. In a case reported by Afanaschiff,^ where a tumor was 
found in the right crus, there was dilatation of the pupil and ptosis. Par- 
tial paralysis of the face, showing involveinent of the seventh, and actual 
deafness, are not rare consequences of injury sustained by the seventh 
nerve." When the fifth nerve is affected, as in one of Broadbent's cases, 
there is generally marked anaesthesia of the region supplied by this nerve, 
with diflScult mastication, deglutition, and articulation. Bed sores are 
not met with in connection with paralysis in cases of cerebral tumor, nor 
do they occur as a result of cerebral pachymeningitis ; they are rather 
the result of hemorrhage into nervous substances. The most im- 
portant evidences are seen at the fundus oculi, and by some optic neu- 
ritis is considered to be a positive sign of brain tumor. Bussel,^ in 
the description of a very instructive case, details an examination of the 
fundus. This may be considered a typical example, although, the retinal 
appearances were in an advanced stage. He found "loss of vision com- 
plete, neuro-retinitis of both eyes. Right disk comparatively invisible, 
even its position not clearly distinguishable. Position of left disk indi- 
cated by short portion of retinal vessels, which were visible near their 
point of convergence. Kegion around the disk in each eye occupied by 
large irregular patches of hemorrhage, some recent, others undergoing 



1 Wieu. Med. Woch., 1870, No. 9. 

"^ H. Jackson does not believe that tumors of the cerebrum or cerebellum produce 
deafness, unless the auditory nervejs, he pressed upon. 
^ Med. Times and Gazette, July 26, 1873. 



208 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



absorption. Only very small portions of retinal vessels are here and 
there visible." 

Complete atrophy of the optic disk is generally to be observed in cases 
where the retinitis has existed for some time. 

Hughlings Jackson calls especial attention to the fact that loss of vision 
is not inseparable from optic neuritis, though complete blindness often 
does occur. He has seen cases in which there was a double optic neuritis, 
though the patients were able to read the smallest type.^ 

A very important appearance observed at the fundus, and known as 
"choked disk" or "congestion papilla," is often produced by brain tu- 
mors. In fact, when not a peripheral condition, it is almost always, ac- 
cording to Swanzy,^ connected with intracranial tumors, hydrocephalus, 
or meningitis ; but when it is produced by these morbid conditions it is 
usually binocular. "Choked disk" maybe caused by a tumor in any 
part of the brain, whether it be in the cerebellum or cerebrum, and it is 
not necessary that the optic nerve shall be implicated either at its origin 
or in its course. Another fact is of importance, viz., that the size of the 
tumor has nothing to do with the production of the condition, and a small 
tumor may produce choked disk as well as a large one. The appearance 
of choked disk is, in substance, the following. The disk may be seen to 

Fig. 27. 




Choked Disk. (After Leibreich.) 

be prominent, the fibres are swollen, and the papillary region is some- 
times of a dark reddish-gray, much change of color being due to passive 
effusion and old hemorrhage. The disk may, in other cases, be of a 
bright color. There may be some evidences of retinal extravasation, 



1 Koyal London Ophthalmic Hospital Reports, vol. iv., 1865. 
■^ Signs of Congestive Papilla or Choked Disk in Intracranial Disease. 
Swanzy, M. B., F. R. C.S., Dublin Journ. of Med. Science, June. 1874. 



H. E. 



BRAIN TUMORS. 



209 



Fig. 28. 



which are not found at any great distance from the edge of the disk, and 
Albutt^ says not more than a distance of the radius from the edge. 
The margin of the disk is concealed by infiltration and by vascularity, 
which give it a "mossy" appearance. The central radiating appearance 
resembles very much a scintillating body, while the retinal veins are dis- 
tended and tortuous, are quite serpentine in their course, and may even 
be varicose. 

I cannot agree with Albutt, who considers the recognition of any prom- 
inence of the disk a difficult matter, and I think that this is the opinion 
of the majority of ophthalmologists. 

As interesting features of this as well as other forms of cerebral disease, 
may be mentioned such ocular trouble as hemiopia and amblyopia. 
Charcot was the first person to consider the significance of these symptoms 
and their connection with hemiansesthesia, and he has done much for 
both neurology and ophthalmology in explaining the direction of the fibres 
in the optic tracts. 

Scheme of the Decussation of the Optic 
Tracts, according to Charcot : T. Semi- 
decussation in the optic chiasma. T Q. 
Decussation posterior to the corpora geni- 
culata. C G. Corpora geniculata. a b'. 
Fibres which do not decussate in the chi- 
asma. b' a. Fibres which undergo decus- 
sation in the chiasma. b' a'. Fibres com- 
ing from the right eye, which meet in the 
left hemisphere, LOG. L D. Right 
hemisphere. K. Lesion in the left optic 
tract, producing right lateral hemiopia. 
L G. A. lesion at this point, right am- 
blyopia. T. Lesion producing temporal 
hemiopia. NN. Lesion producing nasal 
hemiopia. — Ferrier. 

It will be seen by reference to the appended diagram presented by 
Charcot originally, and modified by Ferrier, that complete decussation 
of the fibres of the optic nerve (a a, b'b') does not take place, but that 
certain internal fibres (a' a', b b) decussate in the optic commissure, while 
others decussate further back in the tubercula quadrigemina ; and that there 
is a still further complicated arrangement, so that these fibres ultimately 
centre in the cortex at the pli courbe or angular gyrus. It will also 
be seen how injury to these fibres or pressure by a tumor or other lesion 
may produce several varieties of hemiopia. Ferrier describes the pro- 
duction of visual troubles as follows : " Lesion of the left side of the 
chiasma or of the left optic tract (K), will cause hemiopia of both eyes, 
paralyzing the left aide of both retinae. The external fibres, or those 
which do not decussate in the chiasma, decussate with their fellows in the 




14 



The Ophthalmoscope, etc, 1871, p. 55. 



210 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

corpora quadrigemina (T Q^, and so reach the opposite hemisphere; 
while the fibres which decussate in the chiasma do not again decussate in 
these ganglia, but pass directly through the corpora geniculata (C G) into 
the hemispheres (L G, L D). In consequence of this arrangement, 
all the fibres of the right eye reach the left hemisphere, and all those of 
the left eye the right hemisphere. Hence, lesion of the cerebral centre 
causes complete blindness of the opposite eye, while lesions lower down, 
whether in the corpora quadrigemina, corpora geniculata or optic tract, 
affecting the two sets of fibres before they have run their complete course, 
cause partial blindness or hemiopia of each eye."^ 

Speech is generally involved at some time or other, and psychical trou- 
bles of all kinds, but more frequently the sesthenic forms, make their ap- 
pearance. There is often a condition of hebetude and stupidity which is 
supposed to symptomatize a tumor in the posterior lobes, or there may be 
mental decay of a most grave character. Delusions, loss of memory, 
change of temper, suicidal tendencies, and various perversions of intelli- 
gence may occur in any case. 

A feature of cerebellar tumor, which I find was also observed by Caton, 
was the assumption by the patient of the erect position as a means of re- 
lief from the nausea and desire to vomit. This author,^ in reporting a 
case of cerebellar tumor, alludes to the inability of his patient to regu- 
late his visual co-ordination ; and this seems perfectly reasonable when we 
consider the paralysis of the muscles of the eyeball, and the diplopia, 
amblyopia, and other disturbances of visual regulation. 

The case of Miss F. is in some ways instructive, although it lacks 
completeness, as it does not contain the report of an autopsy, the patient 
being still alive (Oct. 16, 1877) :— 

Miss F., aged 37, U. S. school teacher, was sent to me by Dr. Richard 
F. Derby, in July, 1876. Seven months ago her present trouble began 
with weakness of vision, for which she consulted Dr. Derby, of Boston, 
who adopted Dyerization as a means of treatment. In November, 1876, 
she began to complain of severe localized headache on the leit side of the 
head. This symptom was constant for three months, and towards the end 
of this period a gradual hyper?esthesia of the entire left side developed 
itself, which is now present. It is more decided for three or four days at 
a time, when there is a lull. There is also strabismus, which attends the 
paroxysms of acute head pain, which once in a while recur. In Decem- 
ber, 1876, there was some vomiting, which did not have any connection 
with the fulness or emptiness of the stomach. There is no loss of motor 
power in the upper extremity of either side, but the left leg and foot are 
rather weak, and there is some awkwardness in progression, the toe drag- 
ging slightly. Slight impairment of electro-muscular contractility of 
muscles of leg and thigh. Dynamometer on left side, 9 ; on right, 12. 
Slight ptosis of left eye, occasional diplopia. 



1 Functions of the Brain, p. 168. 

2 London Lancet, Oct. 31, 1785, 



BRAIN TUMORS. 211 

Dr. Derby's record of the examination of her eyes : " Neuro-retinitis 
0. u., with great reduction of vision o. s. ; moderate reduction o. d." The 
patient hears subjective rushing sounds on left side. Is slightly hysteri- 
cal, and suffers from menstrual irregularities. She gives no history of 
any traumatism, no blow or fall, nor previous illness. Her mother and 
father are living, but of decided nervous temperament ; paternal aunt 
and some of mother's connections are insane. Maternal grandmother and 
her brother died of phthisis. The patient has had night-sweats and some 
pulmonary symptoms. There is no specific history. 

Upon a previous visit she stated that there was great formication in the 
sole of the right foot. She afterwards went to her home in Vermont, 
when I lost sight of her, but have subsequently heard of the advance of 
her symptoms. 

The tendon reflex is usually exaggerated upon the paralyzed side ; in 
fact, I have found it to be the forerunner of a hemiplegia, and it may be 
looked upon as a diagnostic sign, or rather a warning, of what may be 
expected. 

Morbid Anatomy. — Without attempting any classification, I will 
briefly allude to those forms of intra-cranial growth most often nif t with. 
Probably that which is most common is Tubercle. Amongst young chil- 
dren tubercle is found sometimes in masses of considerable size ; and, ac- 
cording to AVilks, the cerebellum is its most familiar seat. It is found as 
a cheesy accumulation of dirty green color, and very rarely has the gray- 
ish appearance of the deposit been found- in other parts of the body. 
These masses are rather dry, and decidedly non-vascular, and if a collec- 
tion has been arrested in its growth will be found to be encysted, and may 
be readily removed. If of progressive growth, the limits of the deposit 
are blended with the surrounding brain-substance, and of a contistency 
like cold, white glue. Tuberculous masses are rarely single, but generally 
invade several regions in the same brain, so that it is impossible to give 
any very satisfactory table which will throw light upon the question of 
distribution.^ 

Fox, in speaking of Jaccoud's observations, says : " I much prefer Jac- 
coud's account of these tubercles. They occupy the white and the gray 
substance equally, and present themselves under the form of small iso- 
lated circumscribed masses, varying in number from one to twenty, and 

^ Grat^sef'^ has classified brain tumors: 1. Those of the embryonic tissue (tissn era- 
bryonnaire). These are the Sarcomata — a. Soft sarcotna; 6. Strooma nevroglique 
(glioma) ; c Sarcoma angiolithique (or psammoma). He consitlers that the terms gli- 
oma and psammoma are improperly used ; that the first term suggests more ihe con- 
sistence rather than the character of the tumor. 2. Those of the connective tissue, 
which are — a. Myxoma ; b. Fibroma ; c. Lipoma ; d. Carcinoma ; e. Melanoma. 3. 
Those of the cartilaginous tissue, Chondroma. 4. Those of the ossecxs tissue. Osseoma. 
5. Those of the ephithelial tissue, Papilloma. 6 Those of the nervous tissue, Neuroma. 
7. Tubercle. 8. Syphilitic Tumors. 9. Parasitic tumors (Hydatids). Aneurism. 10. 
Abscesses. 

* Maladies du Systeme Nerveux, Paris and Montpeilier, 1878, p. 302. 



212 



DISEASES OF THE CEREBRUM AND CEREBELLUM. 



seldom exceeding the latter. Their volume is in inverse ratio to their 
number. Pretty often they are the size of a cherry, at other times they 
scarcely exceed the size of a grain of wheat. As to the colossal masses 
which attain to the magnitude of a hen's egg, they result from the conflu- 
ence and fusion of several spots originally distinct."^ 

They are sometimes separated from the nervous substance by a sheath 
of connective tissue and blood vessels. In this connective tissue, which is 
well filled with vessels, according to Virchow, ^ the new granules are 
formed, and are impacted with the central mass, and become cheesy. 
When the process stops, the growth is found to be surrounded by a tough 
fibrous coat, which is sometimes very hard, and even calcified in old cases. 

Ogle^ has reported a case where the tuberculous mass had broken down, 
so that it was soft and pultaceous. In the younger subjects tubercle is 
generally found in other parts of the body. It is quite easy to mistake 
tuberculous growths for those of a gummatous nature. 

Cancerous growths in the brain, which seem to aflPect those of advanced 
age, take much the same form as they do in other parts of the body. En- 
cephaloid and scirrhus are the commoner forms, though melanomata are 
occasionally found. 

The investing membranes may all be the seat of cancer, but notably 
the pia mater and the bony walls of the cranium are its starting points. 



Fig. 29. 



Fig. 30. 




Tubercular Deposit about Vessel. 



Sarcoma. 



In this case the cancerous mass grows inwards, where it meets less re- 
sistance, while cancer of the brain itself grows outwards. Cancerous 
masses are occasionally very large, and in one of Russel's cases (to which 
allusion has already been made) the cancerous mass, which occupied the 
right parietal region, weighed six ounces and a half. These tumors pre- 



^ Fox, op. cit,, p. 151. 

' Cellular Pathology, p. 523. 

» Articles in Br. and For. Med.-Chir. Keview, 1864 and 1865. 



BRAIN TUMORS. 



213 



sent the same characteristics they possess in other regions. The encepha- 
loid variety is very vascular ; the scirrhus not so much so, and is quite 
hard. The carcinomatous growth presents the usual appearance of 
cells contained in the alveoli of a fibrous network or stroma. It may ex- 
ist alone as an intracranial growth, or coexist with cancer of other organs. 



Fig. 31. 



Fig. 32. 




Gumma, 



Psammoma. 



The cancerous growth invades the cerebral substance, though generally 
the dura mater and the other meninges may be the parts at first 
afiected. 

Fig. 33. Fig. 34. 





Encephaloid. 



Glioma, 



Syphilis very often produces changes in the contents of the cranium 
which are quite formidable. Of diffused infiltration I will not speak, but 
of those growths known as gummata, or " gummy tumors." The menin- 
ges and cortex cerebri are commonly the parts which favor the syphilitic 



214 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

deposits, though deeper regions may very often be invaded by the trans- 
lucent reddish-gray tumors of specific origin. The interior is sometimes 
jelly-like and soft, and contains minute red points, while the periphery 
is hard and fibrous. The tumor proper appears to be separated from the 
surrounding brain substance by this fibrous covering, though there is 
always infiltration into the parts adjacent. Syphilitic growths are rarely 
single, and I have seen a number of them in the same brain. Beneath 
the microscope the tumor seems composed of round cells about the size 
of white corpuscles, containing a single nucleus. These round cells oc- 
cupy the centre of the mass while the outer-portion is composed of a net- 
work of connective tissue containing irregular cells. The syphilitic 
growth may sometimes be mistaken for that of a tuberculous nature. 
Niemeyer has reminded us, however, "that in syphiloma the passage 
from the cheesy centre to the broad, grayish-white peripheral zone is very 
gradual, while in infiltrated growing tuberculi these zones follow each 
other more closely, and in tubercules that can be turned out they do 
not exist." The dura mater is very commonly the point of origin. 
This case, for the history of which I am indebted to Dr. Ryan, was 
diagnosed by him during life. The patient was in the service of Dr. 
Mason. 

William Browning, set. 32, native of the United States, boatman, by 
occupation, married, was admitted to the Paralytic and Epileptic Hospi- 
tal of Blackwell's Island, on March 13, 1877. 

The patient says he has always been a hard drinker. Had been a very 
healthy man up to seven years ago, when he contracted syphilis, and has 
since that period been subject, from time to time, to outbreaks of the dis- 
ease in its tertiary form. Two years ago he had a convulsive attack, 
which occurred at night; after which he was out of his mind for three 
weeks. Since that time he has been subject to one or two attacks oc- 
curring every month. Since admission, the patient had four epilepti- 
form fits, characterized by clonic spasms, a confused and perturbed con- 
dition of the mental faculties, but no distinct loss of consciousness. A 
premonitory feeling of great terror was always experienced about ten or 
fifteen minutes prior to the convulsion, and this sense of dread remained 
for some time after each fit ; these seizures being always followed by in- 
tense head iche and debility, which generally lasted for several days. 
The patient's sight has failed greatly for the last year ; unfortunately 
no ophthalmoscopic examination was made. His memory, he said, was 
getting very much impaired, and any mental occupation caused violent 
headache. 

April 28, the date of his last attack, he had been in bed, complaining 
of severe pains in the head, referred chiefly to the frontal region of the 
right side. This pain was always greater at night; the patient com- 
plained of no other trouble, with the exception of great weakness and 
anorexia, until about May 5, when slight paralysis of the muscles on the 
right side of the face was noticed, especially of the orbicularis palpe- 
brarum There was also a distinct loss of muscular power in the left 
upper extremity, which was colder to the touch than the right, and the 
pulse of the afiected limb was feeble and compressible. On May 14 the 
patient became somewhat delirious, and remained so till the time of his 



BRAIN TUMORS. 215 

death. Oq the 17th he began to cough, and expectorated a great quan- 
tity of sero-mucous fluid. Mucous and subcrepitant rales were heard over 
all the anterior surface of both lungs ; a change in the pulse and tem- 
perature, which had previously remained normal, was now noticed; the 
former being 130, and the temperature 103°. Herpes appeared on the 
forehead and lips On the morning of the 18th, patient was in a semi- 
comatose condition. Pulse 160, temperature 104°. He died at 2 o'clock 
P. M. of same day. 

Autopsy twenty four hours after death. Rigor mortis passing off; body 
somewhat emaciated ; suggillation of posterior portion of body. Old 
cicatrices (large) over the left tibia, also several smaller ones scattered 
over exterior and upper portions of body. 

Head : The dura mater is markedly thickened over portion of the 
parietal bone of right side adjacent to temporal bone, and is also adhe- 
rent to a tumor beneath in the brain-substance. On three points on inner 
surface of parietal bone (right) are spots of necrosis, the size of a dime, 
which involve the inner table. The dura can easily be separated from 
the bone, but not from the surface of the tumor. This tumor is three 
inches from above downwards, and two and one-half inches from before 
backwards It is firm, and of a yellowish color- The brain-substance 
directly beneath it is the seat of softening (inflam.), while beyond this 
point, and extending in a direct line to optic thalamus of right side, the 
brain-substance is softened and diffused. The outer border of posterior 
portion of optic thalamus is in the same condition, while the meninges 
and vessels are normal. 

Thorax : Lungs. Bands of adhesion on right side, and a few at apex 
of left. In the lower lobe of right are numerous spots of lobular pneu- 
monia in gray stage. On anterior margin of right lung some emphysema, 
and also at apex of left lung. Otherwise both lungs show marked hypo- 
static congestion and oedema. 

Heart soft and flabby. Seat of post-mortem decomposition. 

Abdomen : Liver increased in length ; evidences of peri-hepatitis. On 
surface of liver are seen several old cicatrices, which dip down into liver 
substance. The parenchyma in patches is softened and fatty (syphilitic 
liver?). 

Spleen increased in size. Capsules thickened in patches ; parenchyma 
difiluent. 

Kidneys about normal size. On stripping capsule it brings away por- 
tion of kidney tissue. Surface appears granular, and in some points 
shosvs lobulation. Section shows tubules swollen, and of yellowish color. 
There appear to be about normal relations between cortical and pyramidal 
portions. Pelvis and ureters normal. 

Bladder, stomach, and intestines normal. 

Parasitic Groivths (Hydatids and Cysticerci). — Hydatids are always 
contained in a delicate cyst (except when they occupy the lateral ven- 
tricles), and there may be several in the same capsule. The cysts are of 
variable size, and sometimes attain the magnitude of a fair-sized orange 
(Reynolds). They are occasionally very large, and the centre of either 
hemisphere seems to be their common site. Cysticerci, which are very 
small, and are sometimes contained in cysts, rarely exceed the size of a 
large marble, but are, however, more often found uninvested, and they 



216 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

may be from one to several hundred in number. They prefer the cor- 
tex, and are often found beneath the pia mater. It seems to me that 
these would be among the most interesting cases for the observation of 
irritation of the motor centres ; usually, however, there are very slight 
indications of their presence. In patients who sufier from cysticerci in 
the brain the diagnosis may sometimes be made by the presence of por- 
tions of taenia in the stools, or a cysticercus in the anterior chamber of 
the lens, which was the case in the example reported by Pollock.^ 

Romberg, while making some experiments, found that the existence of 
C3^sticerci in the cerebelli of several sheep accounted for the peculiar roll- 
ing convulsions that he had observed. 

Cysts, which are not the secondary result of softening or hemorrhagic 
disease, are very rare, and are not usually larger than pin-heads. 

Gliomata, which are directly formed from the connective tissue, are 
more common in the posterior lobes and in the cerebellum than in any 
other locality. The soft and firm are the two varieties. 

Amyloid bodies, connective tissue cells and vessels are found to com- 
pose these tumors, which may sometimes attain a diameter of several 
inches. The peri-vascular spaces are filled with adventitious matter, and 
the calibre of the vessels is very much reduced. These growths may 
undergo fatty degeneration or absorption. The hard varieties, I think, 
predominate, and they are very easy to recognise. 

Papilhmata, both of the vessels and meninges, are not uncommon. 

Myxomata, which Jaccoud describes as having their source of origin 
from the spheno-occipital suture, are quite rare, as are Lipomata. The 
former are usually of large size, have a gelatinous appearance, and at 
times are cloudy. The latter consist of large cells filled with fat, and are 
transparent and shining. 

Sarcomata may be met with as soft masses, which contain " fusiform 
bodies, nuclei, and vessels," or else round cells closely packed. They 
are lobulated, and, when cut, present a pinkish-gray and softened sur- 
face, and sometimes contain central fluid. The soft sarcoma, according 
to Grasset, is found among young children in the deeper parts of the 
brain, and remains dormant for some time, not giving rise to any symp- 
toms, the cells being usually round (" globo-cellulaire "). With 
fatty degeneration the tumor may undergo a change, so that it 
resembles the yellow plates in cerebral softening. It usually has a sur- 
rounding vascular network, and is easily separated from the brain-sub- 
stance. 

Fibrous tumors are quite rare, but are sometimes met with. Lebert has 
seen, in one case, seventeen small fibrous tumors upon the ependyma of 
the lateral ventricle, varying from the size of a pea to that of a small 
cherry-stone. These tumors are of a white color and globular shape, 

1 Wiener Med. Presse., 47, 1878. 



BRAIN TUMORS. 217 

and they are separated from the healthy brain-tissue by a space in which 
the vessels are enlarged. They are easily enucleated, and quite hard and 
dense.^ 

Aneurisms. — One of the most interesting and important forms of intra- 
cranial growths are those of a vascular character. I have taken occa- 
sion to refer to the smaller aneurisms described by Bouchard and Char- 
cot, the so-called miliary aneurisms, which are of minute size ; but large 
aneurisms, arising from such arteries as the middle, anterior and posterior 
cerebral, basilar, and communicating arteries, may be even an inch in 
diameter. These, with miliary aneurisms of small size, are generally 
found to coexist in the brain. Gouguenheim^ and others have found that 
aneurism of the basilar artery was much more common than any other 
form. It is rare, however, that the disease can be diagnosed during life, 
and but two or three cases have been reported where their presence was 
recognized by symptoms, and afterwards verified by an autopsy. One of 
these cases was reported by Coe,^ another by Jonathan Hutchinson,* and 
a third by Humble ; ^ in this case, however, the diagnosis was made by 
auscultation. 

Occasional intracranial growths are the psammomata which are found 
as sandy little bodies scattered overed the dura mater, and have a cal- 
careous formation, feel gritty when rubbed beneath the fingers, and may 
be crumbled. Examined microscopically with a low power they may be 
found to consist of small, compact, round bodies, imbedded usually in 
the dura mater. 

Cholesteatoma, or pearly tumors, which are composed chiefly of choles- 
terine, stearine, and degenerated epithelium contained in an investing 
membrane, are occasionally present in the brain. The latter growths 
are generally found attacked to the meninges or cranial bones, and are 
nearly always superficial. 

The literature of intracranial bony growths contains much that is in- 
teresting. One case reported by Vulpian in the Archives de Physiologic 
was remarkable for the slow development of an exostosis from the tem- 
poral bone, which completely penetrated the Gasserian ganglia on the 
right side. Beyond neuralgia of a severe character, no other symptoms 
were expressed. I have seen many of these bony growths, some of 
them even several inches in length, which had existed for years without 
any mischief being produced. In slow growths there seems to be an ac- 
commodation of the brain so that the pressure is rarely injurious, and it 
is generally not till the exostosis attains some size, and atrophy or soft- 
ening takes place, that bad symptoms make their appearance. 



* Anat. Path., vol. ii. p. 71. 

"^ Gonguenheim, Des Tnraeurs Anevrysmales, etc., Paris, 1866, and also consult 
Smith, Dub. Jour, of Med. Scl, Nov. 1870. 
' Quoted by Holmes. 

* Transactions of the Clinical Society, vol. viii., 1875, p. 127. 
5 Lancet, Oct. 2, 1875, p. 489. 



218 DISEASES OF THE CEKEBRUM AND CEREBELLUM. 

A case which was under the care of Dr. Janeway at the Epileptic 
Hospital is one of the most remarkable of which I have ever heard, and 
I append his very valuable record of the post-mortem examination. 

A. T., aged 42 years ; widow ; domestic. Admitted to Hospital De- 
cember 31, 1872. Patient says that fourteen months ago, as she was 
crossing the ferry, she fell down, and heard people say that some one had 
had a fit. When she came to, she found that she herself had had a 
convulsion. During the attack she was perfectly conscious of all that 
passed about her, and, on arising and attempting to tie her bonnet strings, 
she found that she could not do so on account of what she says was 
numbness of the hands or arms. 

April 29, 1874. For the past five days she has been very dizzy, and 
has had headache, and pain in the left side under the breast. 

SOth. Is in bed. Says " her back feels as if it was breaking in two." 

May 1. Is quite weak. Can move her left leg somewhat, but not her 
left arm ; her emotions are easily excited ; pulse weak ; temperature, 

loir. 

Srd. She lies with eyes half parted, and does not open them fully 
when spoken to. Pupils normal and respond to light. Answers ques- 
tions in a slow, whining tone, and with seeming diflficulty. Does not 
draw up her legs when told, but they respond to reflex irritation. The 
severe pain in her back still continues, and she has some pain under left 
breast. Pain on pressure in the right iliac region. Bowels free ; urine 
normal; respiration normal; temperature 100°. Is somewhat stupid; 
has great pain in back of her head; eyes half closed; conjunctiva not 
very sensitive ; passes urine and feces in bed. 

4th. Sleeping; feces of brown color; urine passed in bed; respiration, 
28; pulse, 88. Feces and urine passed in bed duricg afternoon; tongue 
dry and coated brown. Only partially protruded tongue when told to. 
Eyes half closed; seems brighter; respiration, 36; pulse, 100; tempera- 
ture, 102°. 

5th. Complains of pain in abdomen ; bowels did not move last night ; 
cries w^hen spoken to ; pain in back lighter, but in head is sharp. Pulse, 
88 ; temperature, 100° at 11 o'clock, A. M. Urine highly colored ; no 
albumen. 

10th. Still pain at base of skull. Temperature, 101 f°. 

12^^. Temperature, 1001°. 12 M. Temperature, 99°; headache not 
so severe. 

June 2. No headache ; cries when spoken to. 

Qth. Headache not so severe ; pain in her back. 

10th. Lies with head turned to left. Complains of pain when position 
of head is changed. Headache is relieved by bromide of ammonium. 

19th. Complains of no pain. There appears complete muscular relax- 
ation. Cannot speak without crying. 

20th. Patient is rapidly failing. Temperature, 103f°; pulse, too rapid 
to count; respiration very quick; conjunctiva insensible; pupils respond 
slowly to light. 

21st. This morning about the same ; can swallow wine. Patient sank 
gradually during afternoon, and died at 4.30. 

Post-mortem 18 hours after death. — Heart, liver, lungs, spleen, and 
kidneys normal. An abscess fouud in right Fallopian tube containing 
about 5\j of pus. Rigor mortis not well marked. 



BRAIN TUMORS. 219 

Skull. — On removing skullcap an outgrowth of bone is noticeable on 
the right side, near the central line, just posterior to the groove for the 
middle meningeal artery. The growth is nearly two inches long, and 
one inch wide; raised about i of an inch from internal surface. The dura 
mater was pretty firmly attached at this place, and little pieces were left 
attached to the exostosis. There is another bony projection (small) just 
back of the middle meningeal artery, at the inferior angle of the parietal 
bone. Otherwise interior of skull appears normal. The lowest first (1st) 
is situated just anterior to the fissure of Sylvius, f inch below posteriorly, 
and I inch from above downwards. Elevation, Ifths of an inch. This 
has produced a corresponding depression and flattening of the commence- 
ment of the lower end of the transverse convolution of the anterior lobe. 
Two smaller ones are situated one just i of an inch above it, the other ^ 
inch above, and about i anteriorly. They are nearly half an inch apart, 
the posterior being the longer, and about tis of an inch in diameter. Ele- 
vation, tV inch. 

Around the first large tumor three small ones exist ; the second small 
one is about one-third of the size of the first. A bridge of new formation 
connects this with the two already described. At the point of the large 
exostosis, a number of tumors spring forth from under surface of the dura 
mater, close to one another, averaging If inch in diameter. One of these 
tumors is quite large, and is sunk in a depression in the brain ; the depth 
is 8 of an inch, and it is an inch long and broad. The brain-tissue around 
this is in a state of pulpy softening. The diameter of the softened part 
of brain is two inches, and nearly reaches the longitudinal fissure, ex- 
tending two inches downwards to within two inches of anterior border 
of the brain. The falx throughout its extent is the site of new forma- 
tions, some projecting on the right, others on the left ; one very large one 
in front, which is li inch in length, and has an elevation of Itths of an 
inch ; and another which dips into a depression in the anterior lobe of 
left side. 

The pia mater covering both hemispheres is markedly congested. Tu- 
mors are firm, white, and yield only a thin serous fluid on scraping. 

Diagnosis. — It is a difficult matter, when we consider the great vari- 
ety and irregularity in the appearance of symptoms, to make always a 
correct diagnosis. This branch of neurology is undoubtedly the most 
puzzling, and I am inclined to differ from those persons who consider it 
possible to determine in the majority of cases the exact location of a cere- 
bral growth. The fact that brain-tumors are very often multiple, and 
that secondary lesions are produced, is enough to cool the ardor of the 
most enthusiastic diagnostician. It is possible, however, to sometimes 
make a very close diagnosis. 

We are likely to mistake symptoms of the disease under consideration 
for those of diseases of an organic character. The common lesions 
involving a plugging or rupture of the cerebral arteries of the brain 
may give rise to manifestations much like those produced by intracranial 
growths. 

Paralysis, which is as we know an almost constant symptom of such 
troubles, differs from that of cerebral tumor, not only for the reason I 
have stated, viz. : that there are often local epileptoid symptoms in con- 



220 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

nection therewith, but because the appearance of secondary contractures 
in the paralyzed limbs is rare. I have found an exaggerated tendinous 
reflex in the subject of cerebral tumor, but it was never so general as in 
the other cases, and not attended by spastic rigidity. Then, too, the 
paralytic phenomena prefer local groups of muscles, notably those of the 
face, while hemiplegic disorders are peculiar to cerebral hemorrhage, em- 
bolism, and thrombosis. Sudden paralysis is rare, though it may occur 
from a complicating morbid process ; but it is not uncommon to find a 
disappearance and recurrence. Cerebral tumor is rarely preceded by 
warning symptoms or any adequate cause, except it may be blows upon 
the head, tuberculosis, or syphilis, but there are many cases with no pre- 
vious history of any kind. This history of causes is important to bear in 
mind ; for, whether there be inflammation either of an insignificant kind 
as regards violence, or one of an acute nature resulting in abscess, a his- 
tory of sunstroke, over-work, alcoholism, or aural disease, may be detected. 

Several general diseases may occasionally simulate cerebral tumor, — 
among them uraemia, narcotic poisoning, heart disease, or even hysteria ; 
but it must not be forgotten that hysterical symptoms are not rare accom- 
paniments of organic cerebral diseases, and often of tumor, so that such 
cases are not always the subjects of an easy diagnosis. 

Localized pain and convulsions, with optic neuritis, cranial palsies, and 
vomiting, suggest very strongly the probability of tumor. 

The localization of cerebral tumors has received very extended con- 
sideration during the past few years. In the many cases collected by 
Jackson we are enabled to make a much closer diagnosis than before his 
excellent investigations were presented. Ogle's large number of cases 
are more of interest in the light of morbid anatomy, and as they are 
several hundred in number, almost every variety of formation is to be 
found. Quite recently, an excellent article by Petrina, of Prague,^ has 
appeared. His directions for localization are so complete that I think it 
wise to present them, especially as they are based upon a number of cases. 

I. Tumors of the Convexity. — Clonic spasms limited to single groups of 
muscles on the side of the body opposite to that of the tumor ; no loss of 
consciousness; incomplete hemiplegia, constant headache, decided vertigo, 
nervous irritability; amblyopia and disturbances of hearing; circum- 
scribed aflfection of sensibility. The localization of circumscribed motorial 
disorders is not definite, and can be only limited at present to the region 
of the anterior and posterior central convolutions. 

II. Tumors of the Anterior Lobes. — Frontal headache ; the intellectual 
sphere being involved (?. A. McL. H.) there will be often psychical dis- 
turbances, with chorea ; paresis or hemiplegia (the former more fre- 
quently) ; no disorders of sensibility ; general convulsions with loss of 
consciousness are rare, except when there is deep pressure ; visual disturb- 
ance and deafness, with anosmia. 

1 Vierteljahrsschrift fuer di prakt. Heilkunde, czxxiii. 1. 2. Abstract in Journal 
of Mental and Nervous Diseases. 



BRAIN TUMORS. 221 

III. Tumors of Parietal Lobes. — Hemiplegia on opposite side preceded 
frequently by apoplectic attacks ; aphasia very frequent when tumor is 
large enough to compress the third frontal convolution ; general convul- 
sions with large tumors ; disorder of special sense, except vision, quite 
rare; impairment of cutaneous sensibility common; frontal headache. 

IV. Tumors of the Occipital Lobes. — But one of Petrina's cases pre- 
sented opposite sided paralysis with paralysis of the third nerve on the 
same side ; disorders of intelligence ; convulsions, involvement of organs 
of special sense, cutaneous derangements of sensibility are mentioned 
by Rosenthal and others as pathognomonic ; but are not observed by 
Petrina. 

V. Tumors of the Motor Ganglia. — Hemiplegia on opposite side, with 
loss of consciousness and frequent convulsions ; profound cutaneous anaes- 
thesia when the internal capsule is destroyed ; sometimes aphasia ; corpus 
striatum ; complete hemiplegia with loss of consciousness and convulsions ; 
psychic disorders and irritative motor phenomena, such as tremor and 
choreoid movements ; disorders of organs of special sense are rare, with 
the exception of amblyopia. 

VI. Tumors of Optic Thalamus. — Extensive motorial symptoms are not 
constant, and general convulsions or disorders of sensibility are rare. 
" According as the tumor affects more the bundles of fibres going to the 
optic tracts of those branching out from the cerebral peduncle, we have 
sometimes predominating paralytic phenomena in the optic nerve, altera- 
tions of the pupil and disturbances of the inriervatioQ of the ocular mus- 
cles (nystagmus, exophthalmos) ; sometimes, again, there are the most 
remarkable vaso-motor anomalies of circulation (striking alterations of 
temperature, and cyanosis, or circumscribed redness), as the chief morbid 
symptoms. Pronounced disorders of speech (retarded speech) and of the 
intelligence are symptomatic only of quite extensive tumors in the thala- 
mus ; decided paralytic phenomena are likewise characteristic of simulta- 
neous destruction of the peduncular fibres, or of one of the motor gan- 
glia." 

VII. Tumors in or about the Pituitary Body. — Somnolence, mental weak- 
ness, or apathy ; slowness of speech. Amblyopia and amaurosis are 
common, as well as disorders of other organs of special sense. Rosenthal 
demonstrated that diabetes is an important complication of tumor in this 
region. 

VIII. Tumors of the Peduncles of the Cerebrum. — Vaso-motor disor- 
ders and anomalies of temperature ; early paralysis of the third nerve on 
the same side, as tremor, occasional vesical paralysis ; opposite hemiplegia 
with sensory disorders; intelligence unimpaired; optic nerve often in- 
volved ; involuntary movements of limbs on side opposite to tumor. 

IX. Tumors of the Cms Cerebelli. — Intense headache and vertigo, in- 
voluntary lateral decubitus, rotation of body, one-sided deviation of axis 
of vision, reeling gait, and tendency to fall; commonly disturbances of 
organs of special sense. ( Vide Caton's Case, A. McL. H.) 

X. Tumors of Cerebellum. — Headache quite intense, and limited to 



222 DISEASES OF THE CEEEBRUM AND CEREBELLUM. 

sub-occipital region, vertigo, reeling gait, disorders of co-ordination ; 
paresis of opposite side of body ; convergent strabismus, diminished elec- 
tro-muscular contractility on sound side of head. 

XI. Tumors of Pons. — Cross hemiplegia ; ocular paralysis (convergent 
strabismus), lingual paralysis ; cutaneous anaesthesia, double or single, dys- 
phagia ; disorders of special senses ; facial nerve involved ; crossed sen- 
sory troubles ; vaso-motor disturbances ; vertigo ; increased electro-mus- 
cular contractility of parts supplied by the seventh nerve to galvanic 
current, but not to faradic current. 

Greisinger has written quite fully upon the diagnosis of the character 
of the growth. He considered that convulsion with psychical disturbance, 
but no paralysis, pointed to the presence of cysticerci, because these para- 
sites infest the uppermost layers of the cortex cerebri. 

In one of Jackson's^ cases (No. 13) the signs of an old iritis enabled 
him to make a diagnosis of a gumma. Other marks of syphilitic disor- 
der may be taken into account. Nodes, old scars, eruptions of a tertiary 
character, and alopecia, as well as numerous unmistakable symptoms, 
such as rheumatism, night-sweats, etc., are confirming points in diagnosis. 
Aneurism, Avhich is rare in early life, may be suggested by vertigo and 
subjective noises heard by the patient. In the case reported by Humble 
a diagnosis was made by the stethoscope. Cancerous tumors are very dif- 
ficult to diagnose, the age of the patient and the cachectic signs being our 
only guide, and we are left absolutely in the dark in regard to gliomatous 
and other non-diathetic tumors, although some of the German writers 
suggest that a history of injury generally precedes the first named. Tu- 
bercle may be suspected after a careful inquiry in regard to the patient's an- 
tecedents, and the recognition of the physical signs of deposit in the lungs. 
Parasitic tumors are generally attended by mental decay, and it has 
been stated that epileptiform attacks are the first symptoms of such trouble. 

Prognosis. — Cancerous tumors prove fatal in from two or three months 
to a year, while syphilitic tumors are occasionally retarded in growth, and 
the patient may ultimately recover under energetic treatment, though 
when left alone they rapidly increase in size. I do not believe in the 
spontaneous cure of aneurismal tumors, and feel disposed to consider any 
cases of sudden recovery as anomalous. Holmes says in this connection : 
" We know nothing at present of the diagnosis of intracranial aneurism, 
so that no treatment can as yet be directed specially to it. And, looking 
at the very free intercommunicaticm of the four large trunks which nour- 
ish the brain, it seems unlikely that surgical measures directed to any one 
of them would procure the consolidation of an aneurism situated on one 
of its main branches." The progress of non-diathetic growths is very 
slow, and the patient may live for many years, and finally die of some 
other disease. Gliomatous tumors are perhaps less formidable than are 
others, but after all more depends upon the site of the growth than its 
size and character. Death is preceded in most instances by coma. 

^ Medical Times and Gazette, August 1, 1874. 



DISEASES OF THE CEREBELLUM. 223 

Obernier refers to the increase in growth of cerebral tumors following 
the excessive indulgence in alcoholic drink, and believes that a debauch 
may give rise to violent meningitis and death. 

Treatment. — It has been my practice in every case to place the pa- 
tient upon an anti-syphilitic course of treatment. The iodide, in increas- 
ing doses, until a very large quantity is taken during the day, will some- 
times effect a cure. I have given mercury also, but cannot speak so fa- 
vorably of its virtues. If the pain is excessive, I use the ice-bag, as re- 
commended by Jackson, or the cold water coil of Chamberlain, and find 
that they give great relief. Hypodermic injections are very useful, and 
hyoscyamus and belladonna also do good. Galvanism I believe to be 
useless. Ligature of the carotid has been employed by Coe for aneuris- 
mal tumors, and although it was successful in the case he reports, I am 
inclined to think it is not only a dangerous but an uncertain measure. Hum- 
ble, in commenting upon this and other cases, speaks of Balfour's plan of 
treatment, which consists in the administration of large doses of the iodide of 
potassium. One of the chief indications in the treatment of cerebral tumor 
is the administration of remedies, and agencies that shall tend to diminish 
the excessive termination of blood toward the brain, thus cutting off the 
supply of nourishment as far as possible. A comparatively anaemic state 
of the brain is better than the reverse. We should caution our patient in 
regard to the use of stimulants, and should enjoin early hours, abstinence 
from brain work and rest. Purgatives and local derivatives do much 
good in certain cases. 

DISEASES OF THE CEREBELLUM. 

The cerebellum like the anterior brain, is apt to be the seat of certain 
familiar morbid processes, and among the more common are hemorrhage^ 
tumor, softening, atrophy and the like. Tumor, is perhaps most readily 
diagnosed on account of the slow development of symptoms, and a cer- 
tain degree of uniformity in their appearance, but such is by no means 
the invariable rule. 

General Symptoms of Cerebellar Disease. — The most conspicuous evidence 
of trouble is shown in an uneven exercise of motor power, and this has 
been recognized for many years by all who have had occasion to examine 
cases of this disease. The defective co-ordination is chiefly shown in 
grand movements, such as walking, and in certain cases there is a ten- 
dency upon the part of the patient to fall backward, while in fact in 
nearly all there is a reeling, unsteady walk, that by Hughlings Jackson 
has been compared to the method of progression of drunkards. 

This is increased when the eyes are closed, and just as in some forms of 
other disease, such for instance, as posterior spinal sclerosis, the patient 
cannot preserve his balance when he has no support. Such troubles 
result probably from a certain impairment of the harmony of the visual 
apparatus and the co-ordinating centres, and this in turn undoubtedly arises 
from derangement of the existing relations between the cerebellar fibres 



224 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

and the optic lobes. The patients reel and walk with feet spread widely 
apart. I have repeatedly detected an increase in awkwardness when the 
person looks up, and when the individual makes any sudden and rapid 
forward motion, he often staggers and falls backwards. There is rarely 
paralysis in any form of cerebellar disease until the end, and then it is 
due to complication of other parts, and is accompanied by rigidity and 
local spasms. Jackson has repeatedly insisted upon the importance of a 
symptom of cerebellar disease, and I am able to corroborate what he has 
said, by personal observation of two cases. He calls attention to violent 
and forcible flexion as a phenomenon of the convulsions occurring in 
cerebellar trouble. The head is forcibly drawn backwards, a certain 
amount of opisthotonus is conspicuous, and at the same time there is ex- 
treme flexion of the upper extremities, so that the fists are tightly clenched, 
the elbows are bent, and there is rigidity, of a very decided character. 
This condition is observed most perfectly just before death. The tendon- 
reflex has been found by Sepelli to be present in diseases of this organ. 

The oculo-motor symptoms are also a feature of cerebellar affections, 
and chief among them is nystagmus, the eyeballs being rolled either 
upwards and downwards, or from side to side. The pupillary changes 
following an irritative lesion of this organ consists as a rule in con- 
traction which may vary in extent, and it is not uncommon to find a 
want of response to light stimulation. Amblyopia is apt to occur when 
the anterior and lower part of the cerebellum is involved, and it may be 
either double or single, and is a late symptom of decided significance; in 
a great number of cases optic neuritis is present. 

The general convulsions of cerebellar disease are somewhat peculiar, 
from the fact that there is often rolling of the body which is associated 
with some fixed deviation of the eyeballs. The experiments of Majendie, 
Flourens, Brown-Sequard and Ferrier, prove that these rotatory move- 
ments with the long axis of the body are constant results of cerebellar 
irritation, and they occur in the direction of the affected or irritated side, 
a fact which is of service in localization, as we shall see hereafter. 

There is usually a sense of weariness complained of by the patient, 
though never paralysis, unless other parts are implicated in the diseased 
process. A prominent sensory disturbance is the sub-occipital headache, 
which is distressing and painful, and quite common. There may ex- 
ceptionally be hypersesthesia of the scalp, though an abnormal modi- 
fication of the general cutaneous sensibility is rare. ^ Luys, in 100 cases 
of cerebellar disease, did not find any affection of general sensibility, 
at least anaesthesia which was uncomplicated, in any of them. He, how- 
ever, called attention to what has been observed by Kendu ^ and others, 
viz. : that tactile sensibility is slowly aflTected in cases of cerebellar he- 
morrhage. Affections of special sensibility are common enough, and 
amaurosis may be cited as a symptom of frequent occurrence. It is ex- 

1 Archiv. Gen. de Med, 1864, p. 580. 

^ Des Anesthesies Spontanees. Paris, 1875, p. 51. 



DISEASES OF THE CEREBELLUM. 225 

ceptional that we find any prolonged disturbance of the intellect, as we 
know this region to have little or no connection with the higher mental 
processes. 

CEREBELLAR HEMORRHAGE. 

The symptoms of this form of disease are difficult to diagnose, because 
of the liability of the sanguineous efi*usions to invade other parts in the 
neighborhood, notably the pons and medulla. Hemorrhage limited to 
this region rarely produces loss of consciousness, but leaves a train of 
after-symptoms, which consist of vomiting and ocular disturbances, such 
as loss of vision, contracted pupils, together with clumsiness of speech, and 
probably the uncertain gait which has been before spoken of. If there is 
paralysis, it will be slight and incomplete, unless the outpouring of blood 
be large, and then important adjacent motor regions are involved. 

Carion^ thus speaks of cerebellar hemorrhage : — " The predominating 
symptom of cerebellar hemorrhage is general enfeeblement of the muscu- 
lar system. Hemiplegia is relatively rare ; when it exists it is sometimes 
crossed, sometimes direct. Facial paralysis is exceptional ; it involves 
the orbicular muscle of the eyes, and occurs on the side of the lesion, and 
it has for its cause the compression of the seventh pair at its point of 
emergence. The tongue presents a certain degree of asthenia, shown by 
a weakness in its movements, without deviation. Strabismus, like the 
facial paralysis, is not observed as a symptom of cerebellar origin ; it may 
occur from compression of some one of the motor nerves of the eye. The 
conjugated deviation of the eyes has been observed ; it always occurs 
towards the uninjured side as for other parts of the encephalic isthmus. 
The pupils are sometimes dilated — more frequently contracted; they 
sometimes react under the influence of light, and are insensible. General 
sensibility is unaltered even when hemiplegia exists ; we barely observe 
a slight anaesthesia in a few rare cases ; hypersesthesia is still less frequent. 
Troubles of special sensibility, principally of sight, have been observed, 
but they are very rare exceptions. The intelligence is generally pre- 
served in all its integrity. Vomiting is scarcely ever absent, and it can 
rightly be deemed one of the more characteristic symptoms of cerebellar 
hemorrhage." 

Broadbent reports two cases of cerebellar hemorrhage, which are re- 
ferred to by Wilks. Both cases presented premonitory symptoms of pain, 
but the other evidences were decidedly negative, and might easily be mis- 
taken for those of other diseases. Both patients died from rupture into 
the ventricles. 

A syphilitic endoarteritis may result in complete stenosis of a cerebel- 
lar vessel, so that symptoms of ischsemia are expressed, and become very 
decided if the closure is complete, 

ATROPHY (sclerosis) OF THE CEREBELLUM. 

Atrophy of the cerebellum is very often met with, and in many cases 

^ Abstract in Chicago Journal of N. Disease, vol. ii. p. 62. 
15 



226 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

is recognized only at the autopsy. It is as a rule a condition beginning 
early in life. In those cases I have seen, the atrophy was connected with 
shrinkage of the cerebral roass. On the same side there was generally 
some form of mental imperfection or atrophy of one side of the body. 
Uncomplicated atrophy of one lateral half of the cerebellum I believe 
to be extremely rare. So far as we are able to judge the symptoms are 
those which indicate other forms of cerebellar disease, and it is difficult 
before death to distinguish the condition under consideration from cere- 
bellar tumor of slow growth. There are the disorderly movements, 
chronic spasms, usually some fixation of the head from rigid contraction 
of the muscles of the neck, sometimes a series of movements affecting the 
hands, and which by Sepelli have been described most fully in a case re- 
ported by him. In some respects they resembled those of multiple scle- 
rosis, there being a certain amount of irregular jactitation with tremor 
and a spasmodic expenditure of force. In many cases "atheotoid" 
movements are presented. 

TUMORS OP THE CEREBELLUM. 

Tumors of the cerebellum may resemble in every respect those found 
in other parts of the brain, so far as their general structure and topo- 
graphy is concerned. Headache is usually a severe and constant symp- 
tom, and is referred to the back of the head, while convulsions are quite 
severe as a rule, and become more and more violent and frequent as the 
bulk of the growth increases. Ocular troubles, such as amaurosis, strabis- 
mus and pupillary changes symptomatize the presence of growths in this 
region, and it is common to find decided retinal changes, such as atrophy 
and hemorrhage. The disorderly movements, which, if once seen, can 
scarcely be mistaken a second time, are nearly always present, and are 
connected sometimes with tremor and special paralysis of the cranial 
nerves. Alteration of the muscular sense and the faculty of localization 
and sensory perception are quite common. Dr. Webber ^ reports an in- 
teresting case of cerebellar tumor with headache, vertigo, vomiting and 
a species of convulsive attack with aura. There was atrophy of both 
optic nerves and some unequal anaesthesia of both sides of the body, the 
left leg and right hand being affected. The patient died suddenly. 

" Autopsy. — Brain only was examined. There were a few spots of in- 
creased opacity of the pia mater over vertex. Convolutions universally 
flattened. The ventricles contained a large amount of serum, twelve to 
fifteen ounces, much of which was lost and not measured. On the under 
surface of the cerebellum in the median line, between that organ and the 
medulla oblongata, extending a little farther to the left than to the right, 
was a tumor; this involved both lobes of the cerebellum and measured 
about three inches transversely. The medulla oblongata was much com- 
pressed and flattened. The tumor contained five cysts : two of which 
were very large, and two others very small ; a large cyst projected ante- 
riorly from above the cerebellum below the corpora quadrigemina. Sev- 

^ Boston Med. and Surg. Journal, April 8, 1880. 



DISEASES OF THE CEREBELLUM. 227 

eral of the nerves arising from the medulla were thinned, and less white 
than usual." 

In this case, as in many others, the symptoms developed slowly, and 
the headache before death was much less severe than the beginning, be- 
cause of the capacity for accommodation to pressure upon the part of 
the cerebellum, which, as we know, is not readily a ffected by ordinary 
mechanical injury. So, too, it would seem that the more serious mani- 
festations of symptoms depend upon invasion of other territories. In 
most of the cases of cerebellar disease I have been able to investigate, 
death resulted from softening or injury extending to the floor of the 
fourth ventricle, or from the bursting'of some vessel submitted to danger- 
ous pressure, so that the ventricular cavities become flooded. In this con- 
nection may be mentioned a case in which the post mortem examination 
was of great interest. 

G. L. C, get. 26, of nervous temperament ; general health good ; pa- 
rents both alive ; no nervous tendency ; never had syphilis. Four years 
ago the patient became irritable and morose, and continued so till January, 
1873. He then devoted himself to hard study, and rarely took exercise 
or amusement. Two months afterwards he became debilitated, and had 
attacks of vomiting, which occurred in the morning, and were relieved 
somewhat by the upright position. In the following April a loss of 
steadiness of the lower limbs was noticed. He reeled, and a sudden 
fright would cause him to fall. He no longer went alone on the street ; 
when he did so, he reeled, staggered, and felt conscious that he was the 
object of curiosity. His face became congested, and his nose very red, 
although his habits were good. He went to the seashore, but never- 
theless grew worse, and derived no benefit from the change. About this 
time diplopia troubled him, and he tried various devices to correct this 
visionary difiiculty, such as shutting one eye and looking across his nose 
with the other, but without relief. In August, violent headache developed 
itself, and vomiting was frequent. He could not look up or throw his 
head back without dizziness and pain. Cathartics and local blisters did 
no permanent good, nor did the bromides. 

May, 1875. The patient presents the same symptoms. He is very 
much troubled by headache, which is paroxysmal. He staggers wildly, 
and his vision is not improved. On the day before his death he went to 
see some friends, and on his return complained of a terebrating pain in 
the back of his head. He went to bed, and slept, under the influence of 
chloral hydrate. When his wife awolce in the morning, she fourd him 
dead. He had evidently died without any convulsions, or she would have 
been aroused. The night before his death there was some mania, and he 
shouted words of the different languages he spoke — German, French, 
Italian — in a confusing jargon. 

At no time was there impairment of speech or deglutition ; there were 
never ptosis, deafness, loss of smell or taste. Paralysis was never observ- 
ed, nor were there convulsions of any kind. 

Autopsy eight (?) hours after death. The scalp was cut through, and 
the exposed surfaces were almost black with blood. On removing the 
bone the meninges were found hyperaemic to a marked degree, the spaces 
were engorged beneath the arachnoid, and in the ventricles was a large 



228 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

amount of yellowish fluid, the former being puffed out by the serum 
under the surface. Nothing unusual was noticed in the hemispheres 
beyond the hypersemia before alluded to, and careful slicing of the basal 
ganglia revealed nothing of importance. The texture of the nervous 
substance was normal. At the base of the brain a very different state 
of affairs was found to exist. From before backwards there were evi- 
dences of acute inflammatory action, the left side more particularly 
being the seat of softening. The right crus of the optic commissure 
was very much disorganized. There was a well-organized membrane, 
very pink and net-like, which extended over the inferior surface, one 
band binding down the left root of the optic commissure. 

Beneath the lining membrane of the fourth ventricle, at a point 
beneath the lower and anterior part of the cerebellum, was an effusion, 
with softening of this organ. This membrane was bellied out, and had 
evidently produced death by direct pressure upon the calamus' scrip- 
torius. 

At a point corresponding to the middle of the lower vermiform pro- 
cess of the cerebellum was a small hard tumor, about two centimetres 
in length, one and a half in breadth, and the same in thickness, which, 
when cut, disclosed a red jelly-like centre, and a hard fibrous exterior, 
resembling, somewhat, a syphilitic growth. The line of demarcation 
between the healthy tissue and the circumference of the tumor was very 
well marked. Beneath the microscope Dr. E. G. Janeway and I found 
it to be a glioma of the firmer kind, there being a fibrous structure con- 
taining the characteristic cells. 

After hardening pieces of the cerebellum and the medulla oblongata, 
I examined them microscopically. The evidences of disorganization of 
the nervous elements at the nuclei of the vagus were apparent. The 
nerve-cells were deprived of their processes, and the nerve-tubes were 
broken. The sections of the cerebellum were made contiguous to the 
tumor, and here I found considerable thickening of the neuroglia and 
disappearance of nerve-tissue, while the vessels were very much increased 
in size. 



Strange as it may seem, it would appear as if the progression so far as cure 
is concerned is not hopelessly bad as the nature of the lesion would lead 
us to suppose. This is especially true in syphilitic tumor, and I have kept 
the notes of several cases in which cerebellar tumor was diagnosed and 
cures were effected in a remarkably short space of time. In one patient 
the symptoms had existed for ten years, but after the diagnosis of syphilis 
had been made, and mercurials had been administered, a rapid subsid- 
ence followed, and the patient was almost entirely cured within a year. 

As a rule, the symptoms of cerebellar tumor of syphilitic origin are 
complicated by those of meningitis, as tumors of this character start from 
the investing membrane and grow inwards. 

In a few cases of cerebellar tumor I have witnessed mental symptoms, 
but these are rare. In the case of G. C, an attack of maniacal excite- 
ment preceded death. We, not unusually, meet with cases, however, in 
which there are hysterical complications, just as there are in right-sided 
organic disease of the cerebrum. 



DISEASES OF THE CEREBELLUM. 229 

Aneurismal dilatation of the arteries supplying the cerebellum are 
occasionally met with, and such a case is related by Bristowe.^ 

J. B., a lighterman, was admitted on the 26th of October, 1858, for an 
attack of acute rheumatism (gout?). No distinct account of the previous 
duration of his illness was obtained. Five days after admission he com- 
plained of severe epigastric pain, and had some vomiting. Shortly after- 
wards he became comatose, and continued so until his death, which took 
place on the 2d of November. 

Fig. 34 a. 




Cercij^i.c. .:^iieurism. (Bristowe). 

Post-mortem Examination. — There was a considerable amount of serum 
both on the surface and in the ventricles of the brain ; and much athero- 
matous and earthy deposit in the arteries at the base, and their branches. 
In the right corpus striatum was a small apoplectic cyst, but in other 
respects the brain-substance appeared healthy. In the substance of the 
right hemisphere of the cerebellum was accidentally discovered an aneu- 
rism about twice as large as a grain of wheat ; it was irregularly fusiform, 
its parietes were thickened and hardened with atheromatous and earthy 
deposit, and it gave off several partly ossified branches, each about half a 
line in diameter. Its anterior extremity was continuous with a thin 
walled healthy vessel, having between one-third and one-half the calibre 
of the aneurism itself, and found to be a branch of the right superior ce- 
rebellar artery. Gouty indications were found at different points. 

SOFTENING AND ABSCESS OF THE CEREBELLUM. 

Acute and chronic softening are met with in this organ — and as a result 
it is not rare to find abscess. Cerebellar abscesses are formed in this 
way, or depend upon the breaking down of an old clot, as w^as the 



^ London Pathological Society's Eeport, vol. x., p. iv. 



230 



DISEASES OF THE CEREBEUM AND CEREBELLUM. 



case in an example reported by Dr. Hughes, of St. Louis/ the main 
symptoms of which are the following : — 

" He has a sense of fulness in the head, headaches daily, with intensi- 
fied pain and throbbing in the occipital region, especially severe in the 
morning after breakfast. He has a ravenous appetite ; vomits often, es- 
pecially after eating, and has dizzy spells. 




A, Abscess.. B, Cyst containing serum. C, Organized apoplectic clot. . 

Before the headaches came on he would sometimes sleep twenty-four 
hours without waking. When attempting to walk, he often staggers as 
though he were drunk. 

He sometimes hesitates for words to express his ideas, but not enough 
to be called aphasic. 

Three weeks before coming under my treatment, he was much out of 
his head. He became wild and delirious, and engaged in an imaginary 
fight with his wife and boy, taking down his gun from over the door to 
shoot them, saying he must defend himself. He had but a confused re- 
membrance of the fact afterwards. He complains of a sound as of hiss- 
ing steam in his ears. 

His sexual appetite was neither absent nor inordinate, so far as we 
could discover. His mind was clear up to the hour of his death, and a 
few hours before that event he walked, though somewhat clumsily, about 
his room. A few minutes before he died he sat up in bed, clasping his 
hands to his head and crying out with intense pain. He became coma- 
tose without convulsive or other premonitions, and fell back on his pillow 
and in a few moments expired. 

On removing the cerebellum, pus and serum escaped through a small 
opening in the membrane not caused by laceration or scalpel puncture. 

The abscess occupies the lower half of the left hemisphere of the 
cerebellum, extending forwards and upwards, so as to obliterate all 
traces of the corpus dentatum, and backward and downward, so as to 



^ Journal of Mental and Nervous Disease, October, 1877. 



DISEASES OF THE CEREBELLUM. 231 

communicate with an apoplectic cell, about the size of a hazel-nut, filled 
with serum. 

This cell extended from the surface through the arbor vitse arrange- 
ment, and opened into the abscess. 

The cavity of the abscess was immediately above and contiguous to the 
organized apoplectic cyst, located just beneath the arachnoid membrane, 
and occupying the striated structure at the extreme posterior inferior 
part of the left cerebellar hemisphere, and just within the median line. 

This organized blood-clot, though now a little shrunken from long im- 
mersion in alcohol, was about the size and shape of a butter-bean. 

The apoplectic products did not invade the right hemisphere. The 
abscess did not implicate any part nearer the middle of the tuber annulare 
than one and a quarter inches, and of course did implicate the crus cere- 
belli. 

The cavity of the abscess was large enough to envelop a large-sized 
almond, and was filled with pus. 

A careful examination revealed no lesion of the cerebrum. 

The weight of the brain, including the pons varolii, medulla oblongata 
and membranes, was forty-eight ounces and a half. The weight of the 
cerebellum, medulla and pons, after evacuating the abscess and cell of their 
pus and serum, was four and one half ounces. 

The opposite cerebellar hemisphere appeared neither congested nor in 
any other manner diseased. 

There do not seem to be any very peculiar or distinctive symptoms of 
cerebellar abscess. In many cases, in fact in enough to give the symp- 
tom more importance than it receives, there is deafness. The patient is 
more comfortable in the upright position, and there seems to be more fre- 
quent vomiting than in other forms of cerebellar diseases. 

The coexistence of aural disease sometimes, either leads us to ignore 
the cerebellar trouble, or decide at once that the latter is a result of the 
former, which is not always warrantable. The diagnosis is sometimes 
made by the ophthalmoscope, and I may refer to Hughlings Jackson,^ who, 
in alluding to the importance of this instrument, insists upon the point 
that very often we have no reason to suppose that there exists any impair- 
ment of the visual apparatus, at least so far as the patient's ability to 
read is concerned. 

In a case seen by him the symptoms pointed strongly to aural dis- 
ease with cerebellar symptoms, but an ophthalmoscopic examination re- 
vealed double optic neuritis, though there was no cranial nerve paraly- 
sis. She saw perfectly, though her retinae were the seat of disease. A 
post-mortem examination revealed an abscess in one-half of the cerebel- 
lum of great size. 

Pathology and Morbid Anatomy. — The results of much experi- 
mentation show that injury or disease of the cerebellum is followed not 
only by special symptoms, but by others indicating disturbance of the 
conjoined function of the cerebrum and cord, and that as this organ 

^ Eemarks upon the routine use of the ophthalmoscope in Cerehral Disease, p. 16. 



232 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

is the seat of the so-called " muscular sense,"* there is an impairment 
or abolition of this function as well. The cerebellum seems to play a 
regulating part, if such an expression can be used, for there are a 
number of indirect disturbances in the functions of the anterior brain 
which are produced. Bastian refers to the liability of the cerebrum to 
suffer in such cases by reason of mechanical vascular interference. 
The vense galeni which empty into the straight sinus are subject to pres- 
sure when the middle lobes are affected. This in some measure accounts 
for the indirect production of hemiplegia in a number of cases of cere- 
bellar disease while in other forms in which there is very decided de- 
struction of the cerebellum, no real paralysis occurs but simply a " weak- 
ness." When hemiplegia occurs it is sometimes due to pressure upon the 
medulla, and is irregular in its production. When one lateral half of 
the cerebellum is the seat of injury, we have hemiplegia upon the same 
side of the lesion, " an effect really induced by the pressure which such 
lesion occasions upon the corresponding side of the medulla oblongata." 

Irritation of the cerebellum by means of electricity has been found by 
Hitzig^ to result in a peculiar train of phenomena. A galvanic current 
passed through the head, the electrodes being placed upon either mas- 
toid process, produces immediate dizziness and a disturbance of equili- 
brium, depending upon the position of the anode and cathode.^ The 
passage of the current from the right to left, the anode being placed 
upon the right mastoid process, causes a vertigo in which external ob- 
jects move from right to left, and according to Ferrier, when the subject 
closes his eyes he feels as if he were being twirled from right to left ; a 
contrary state of affairs occurs when the poles are reversed. The eye- 
balls are directed to the side of the body towards which objects seem to 
move. 

So far as the loss of equilibrium is concerned, it has been found that 
the most active expressions of disturbed motility follow immediately after 
the injury or occurrence of the lesion, and Ferrier says take place as a 
result of the " sudden derangement of the self-adjusting mechanism on 
which the maintenance of the equilibrium mainly depends." 

It would appear from the records of ninety-three cases brought together 
by Andral, and a dozen or more cases collected by Hughes, that a very con- 
siderable destruction of the cerebellum may take place without any con- 
spicuous alteration of functions so far as motility is concerned ; and it 
would also appear that the morbid processes characterized by hyper- 
trophy or tumor are those in which the most decided phenomena are pre- 
sented, and presumably as a result of pressure made upon other parts. 
From the physiological experiments of Ferrier and the clinical observa- 
tions of Bastian and others, we may roughly approximate as follows the 
localization of cerebral disease : 

Injury or Disease of the Middle Lobes. — Pitching forward of the body. 

^ Quoted by Ferrier, page 106. 
^^ Anode : positive. Carthode : negative. 



DISEASES OF THE CEREBELLUM. 233 

Affection of vision due to irritation of optic lobes. If the upper part is 
affected : nystagmus to the right horizontally — if the lower, in the reverse 
direction. Symptoms indicative of cerebral pressure due to ventricular 
dropsy. Increase of sexual power (?). 

Injury or Disease of Lateral Lobes. — Rotatory movements towards dis- 
eased side (Schiff, Ferrier, Hitzig, and others). In cases of limited dis- 
ease there is a tendency to fall towards side of lesion, rolling of eyes up- 
wards, inwards, and towards side of lesion. Hemiplegia, perhaps, and 
when found, it is more marked in the leg than arm, and is accompanied 
by loss of sensation. If one lobe is affected, there is rarely decided loss 
of power, but unsteadiness and weakness. No affection of speech or 
deglutition. 

Injury or Disease anterior of Anterior Region. — Vertical nystagmus, 
complicating cerebral disturbance. 

The morbid anatomy of the cerebellum presents a large field for study; 
and Pierret, Meynert, Fischer, and Sepelli have recently written a great 
deal that is valuable. Disease of this organ presents ultimate textural 
changes that differ but slightly from those which affect other parts of the 
brain. The commissural fibres are often found to be the seat of degene- 
rative changes which may extend to the cerebrum and the cord, and it is 
not uncommon to see atrophy and sclerosis of other organs in the vicinity 
in connection with morbid processes in the cerebellum itself. In some 
cases the pons is greatly diminished in size, -while it is to be observed in 
others that the cord is the seat of secondary degeneration, as a result of 
downward extension of cerebellar disease ; but this is not nearly so com- 
mon as when it follows cerebral disease. When such secondary degene- 
ration exists, it may be explained by reference to the anatomical relation 
of the series of fibres that pass either across the median cerebellar pedun- 
cle or through the medulla to enter into^ the formation of the anterior and 
lateral columns. It follows in certain cases, therefore, that secondary 
contractions are to be met with ; and in a patient who died at the 
Hospital for Nervous Diseases, there was besides atrophy of the cere- 
bellum and cerebrum, a hemiplegia with secondary contractures and 
sclerosis of the cerebellar peduncles. In many cases the cells of Purkinje 
will be found to be altered, having undergone granular changes. Soften- 
ing is common, and this may be readily inferred when we take into 
account the rich vascular supply of this organ. 

In "different cases of abscess of the cerebellum, the size of the purulent 
collection will vary greatly, and frequently one-half of the organ is found 
to be the seat of a cyst filled with pus. As in Hughes' case, these cysts 
often follow old hemorrhages. ^ Fox presents a case in which cerebellar 
abscess existed together with small abscesses of the cerebrum and lungs, 
and another in which a large abscess in the central part of the left hemi- 
sphere of the cerebellum existed with distended ventricles. In neither of 
these cases was there any apparent cause. 

^ Pathological Anatomy of Nervous Centres. 



234 DISEASES OF THE CEREBRUM AND CEREBELLUM. 

The vessels liable to rupture are the inferior cerebellar arteries, the 
posterior being a branch of the vertebral, and the anterior a branch of the 
basilar. The vessel however most frequently found ruptured is the su- 
perior cerebellar artery, usually at a point where it gives off a branch to 
supply the rhomboidal nucleus. The arrangement of the vessels is double 
and there is free anastomosis. As in other parts of the brain, the hemorr- 
hages into the gray substance are the most extensive, and this is especi- 
ally the case when the superior cerebellar artery is ruptured. 

Atrophy of the cerebellum is usually a congenital state, although it 
may follow low inflammatory processes, or be due to osseous deformities, 
as in the case cited by Otto. Meningeal thickening may induce atrophy 
by pressure. 

As to cerebellar tumors, we find that glioma prefer this seat, though 
tubercule is by no means rare. 

Diagnosis. — Cerebellar disease may be confounded with several other 
forms of trouble producing disorders of motility. Chief among these are 
anomalous varieties of locomotor ataxia, in which head symptoms are 
marked. There is never, as I have stated, any disappearance of the ten- 
don reflex, though atrophy of the optic nerves may be present in both 
diseases. I have repeatedly met with cases in which the diagnosis, so far 
as the gait was concerned, was extremely difficult. In cerebellar diseases 
there are none of the sensory disturbances so marked. The neuralgic 
pains in the lower extremities and anaestheria are therefore absent,.as 
are the crises gastriques. The differential diagnosis between cerebellar 
hemorrhage and that in the cerebrum is not so difficult, for there is rarely 
any loss of consciousness, unless the hemorrhage is sufficient to flood 
other parts. The symptoms are characterized by their regularities in 
their grouping. A point previously stated should be borne in mind, and 
this is, that the paralysis — if it \)e present — is much more profound in 
the lower extremities, and that facial paralysis is rare, a point insisted 
upon by Bastian. In the various forms of cerebral sclerosis the diagnosis 
is quite difficult; in fact, the cerebellum is rarely the seat of limited 
sclerosis, as in cases reported by Charcot and Bourneville other parts of 
the brain were affected as well. 

In a great many cases disease of. the cerebellum gives rise to convul- 
sions, which are mistaken — and not without reason — for epilepsy. They 
are irregular, however, and connected with such marked tonicity that they 
need not mislead. Moreover, they often occur without loss of conscious- 
ness, and are connected with vomiting and nystagmus, and are always 
bizarre and rotatory. 

Prognosis. — The most faithful and intelligently selected treatment 
avails but little in cerebellar disease, except in certain exceptions. Syphili- 
tic disease, in this region I have found, as I have before said, to be much 
more effectively combated than when it involves other parts of the brain. 
The progress of cerebellar disease is so slow, and, as a rule, is so rarely 
attended by serious symptoms as to be less alarming to the patient and 
physician than where the pathological process involves some other region. 



DISEASES OF THE CEREBELLUM. 235 

Treatment. — The managemeut of these cases is very much like that 
which should be followed in general cerebral disease. The iodide of 
potassium in large doses, arsenic in the form of Fowler's solution, or the 
bi-chloride of mercury may be given a thorough trial. Counter-irritation 
by means of a seton, or frequent cauterization of the neck, should be re- 
sorted to as well. 

In a case of syphilitic origin I had the pleasure of witnessing a very 
rapid disappearance of symptoms when the patient was submitted to sys- 
tematic inunction with mercurial ointment. For the relief of the intense 
headache, the ether spray to the occiput, or ether applied on cloths to the 
head, as recommended by Dr. Hughes, affords great relief. 



236 DISEASES OF THE SPINAL MENINGES. 



CHAPTER YIL 

DISEASES OF THE SPINAL MENINGES. 
SPINAL MENINGITIS. 

ACUTE PACHYMENINGITIS. 

The investing membranes of the spine may be the seat of chronic or 
acute inflammation, together or singly, though there is generally a cer- 
tain amount of coexisting myelitis, and consequently the meningitis is not 
an uncomplicated condition. In exceptional cases, however, the dura 
mater may be affected, and the resulting affection is known as Spinal 
Pachymeningitis ; or the pia mater and arachnoid in other cases are the 
seat of such inflammation ; or the three membranes may be together in- 
volved. 

INFLAMMATION OF THE SPINAL DUEA MATER, OK SPINAL 
PACHYMENINGITIS. 

Midland ^ has given the name external pachymeningitis to the form 
which results from pressure made by diseased vertebrse, and coexisting 
with Pott's disease, while other varieties have been described as internal 
hemorrhagic pachymeningitis (Meyer ^ and Schuberg'^) and cervical hyper- 
trophic pachymeningitis (Charcot *). The form described by Meyer is 
almost identical with that which involves the cerebral dura mater, and in 
which there is thickening and encysted clots. As the name indicates, 
the form described by Charcot is confined chiefly to the cervical portion 
of the spinal dura mater. 

ACUTE AND CHRONIC SPINAL MENINGITIS. 

Symptoms. — This disorder, which commonly involves all three mem- 
branes, is generally ushered in by a chill, followed by elevation of tem- 
perature ; a hard, fall pulse, and excruciating pain. This pain is increased 
by any movement the patient may make. He tries to relieve his suffer- 
ing by changing his position and by keeping quiet, so that muscular rigid- 

^ Sur la Meningite, etc. These de Paris, 1871. 

^ De Pachymeningitide, etc. Dissertatio inaug. psych. Aug. Meyer. Bonnae, 
1861. 

^ Vicli. Archive., t. xvi. p. 481. 

* Lecons sur les Fonctions dti Sys. Nerveax, fas. 1, part 2, p. 243, etc. 



SPINAL MENINGITIS. 237 

ity, which is semi-voluntary, is often mistaken for a tetanic spasm. Pain 
darting along the spinal nerves adds all the more to his misery, and his 
legs are forcibly drawn up. Hypersesthesia of the surface is generally 
present, and reflex excitability is nearly always exaggerated in the earlier 
stages. The head is sometimes drawn backwards by contraction of the 
post-cervical muscles, and the appearance is presented which is so well 
marked in cerebro-spinal meningitis. Should the meningitis be general, 
or extend upwards, the intercostal and phrenic nerves are finally involved, 
and asphyxia and death result. The tendency in many cases is towards 
chronicity, and very often there are secondary affections of the cord from 
pressure. The bladder and rectum frequently suffer to such a degree that 
involuntary discharges of urine and feces result, but the former some- 
times escapes the involvement. Should the disease become chronic, it 
exists in a modified form, the pain being less severe, and the contractions 
of the limbs more marked. The skin is cold and hypenesthetic, and re- 
flex excitability is present to an extraordinary degree, the slightest prick 
of a pin being sufficient to cause violent retraction of the limbs. The 
muscular power is greatly reduced, so that the individual may be unable 
to take any exercise. The bladder trouble is much more marked than in 
the acute variety, and the patient may find it necessary to empty his blad- 
der every few minutes. Obstinate constipation, distension of the bowels 
by wind, and gastric disturbances, are accompaniments. If the cord is 
involved, there may be presented symptoms of meningo-myelitis, and then 
paralysis of motion and sensation becomes marked, and the muscles under- 
go atrophic changes. 

The case of Mr. J. E. is instructive. He is a great sportsman, and up 
to four or five years ago was often exposed during his hunting, excur- 
sions. Four years ago, during one of these, he lay for several hours in 
a " battery," shooting ducks. The weather was cold, and he was directly 
exposed to a drizzling rain. On the same night he was seized with a 
chill, which lasted for nearly an hour, and, supposing he had "caught 
cold," he drank altogether nearly a tumblerful of whiskey. During the 
night he became feverish, complained of pain in the back, vomited, and 
was delirious throughout the next day and the two following. His pain 
was excruciating, and the slightest jar of the bed caused him intense 
agony. At the end of fourteen days he was moved upon a mattress to 
the nearest boat, and from thence to the railroad, and was carried to his 
home by easy stages. For a month or go after, he was confined to his 
bed, the pain gradually becoming less intense, and his strength returned 
by degrees. He presented himself to me with the history I have just 
detailed. For the past year he has had spinal pain, which he refers to 
the last dorsal and upper lumbar vertebrae. It is constant and worse at 
night, and increased by pressure. There is gastrodynia, and pains down 
the back of the thighs, which seem to increase after exercise. He com- 
plains of loss of power in the legs, and cannot walk more than a block 
or two without being greatly fatigued, and at night his legs are jerked 
up during sleep. For the past year he has had great distress and dis- 
comfort, as he cannot hold his water, and is obliged to empty the blad- 
der every few minutes. His bowels are so constipated that he finds it 



238 



DISEASES OF THE SPINAL MENINGES. 



necessary to use an injection every night. Examination revealed pain 
upon pressure over the two lower dorsal vertebrae, analgesia and anaes- 
thesia of the cutaneous surface of the posterior region of thigh. The 
glutei muscles, as well as the adductors of the thigh, were much reduced 
in size, and did not contract as powerfully as did those in the neighbor- 
hood when subjected to electrical stimulus. His abdomen was tympanitic 
and greatly distended. He had become despondent during the past 
year, and neglected his business. In addition to the pain, loss of power, 
and the other symptoms I have enumerated, there has been a sense of 
abdominal constriction at the level of the painful point. Damp weather 
aggravates the pain, and he has periods of improvement, when he goes 
to Florida or some other warm region. 

^ SPINAL PACHYMENINGITIS. 

Symptoms. — The forms of pachymeningitis cannot be during life 
separated as a rule. There may be no acute stage whatever, but a 
gradual appearance of symptoms indicative of slowly developed pressure 
upon the cord. The form described by Charcot ^ runs its course in five 




Deformity of Hand in Cervical Pachymeningitis (Charcot). 

or six years, and the cervical enlargement of the cord is the part which 
suffers the most. Pressure is made upon the cord itself, and upon the 
nerve-trunks, so that partial or total loss of function ensues. There is a 
painful stage, the premiere periode of Charcot, which lasts several months,, 
the pain being intense at the back of the neck and in the upper extremi- 
ties. With these pains there is rigidity of the upper extremities, and the 
head is drawn backwards and downwards in the manner I have before 
described. There are in addition formication and disagreeable sensations 
in the upper extremities, twitching, and some paresis, which ultimately 



Op. cit. 



SPINAL MENINGITIS. 239 

increases, so that the individual retains but little power. Charcot has 
observed eruptions of bullae and pemphigus as evidences of lowered vital- 
ity. After this period there is atrophy of the paralyzed muscles, partic- 
ularly those innervated by the ulnar and median nerves, while those 
which are supplied by the radial escape the atrophic change, and deform- 
ity often results which somewhat resembles the main e^i griffe of pro- 
gressive muscular atrophy, diminution and loss of electrical excitability. 
The preceding cut from Charcot represents the appearance of the hand 
in this condition. 

Contractions of the paralyzed muscles ultimately follow the paresis, 
and the skin becomes decidedly anaesthetic, so much so that a pin may be 
inserted without any expression of suffering from the patient. It is very 
rare for the lower extremities to be implicated, and the medulla seems to 
escape the effects of the disease, consequently troubles of deglutition or 
respiration are rare. The hemorrhagic or internal form of pachymenin- 
gitis runs a most irregular course, but the complicating spinal affections 
are apt to be much more marked than in the last-mentioned variety. The 
indications of internal pachymeningitis are throbbing pain in the back, 
sudden paralysis, and the other symptoms to which I have alluded. The 
disease is connected with hemorrhages, and consequently there are at in- 
tervals accessions of fresh symptoms. 

In a large number of cases the symptoms may be due, in the first place, 
to pressure from diseased or fractured vertebrae, and pronounced pain of a 
somewhat local character is a prominent initial expression of trouble, and 
this will be followed by other symptoms, at first comparatively localized^ 
but eventually, the pain will extend, and descending or ascending ex- 
pressions of compression of the cord will be manifested. 

The large number of cases which were known as " syphilitic paraple- 
gia " some years ago include many examples of chronic syphilitic pachy- 
meningitis, which were then recognized as the result only of myelitis. 
The progress of the disease is much more slow than in other forms, and 
the patient lasts a very long time, and is sometimes quite cured by appro- 
priate anti-syphilitic remedies. The acute zymotic fevers are not rarely 
followed by pachymeningitis, the following case being an interesting 
example of this occasional sequel of typhoid fever : — 

Two years ago Capt. S. recovered from an attack of typhoid, and with 
convalescence he gradually lost power in the right hand, right leg, left 
leg, and left hand, in the order I have named them (this is his statement). 
Preceding these conditions there were shooting pains running down the 
spine and around the body. He was paraplegic two months afterwards. 
During this time reflex movements were easily provoked. " When my 
feet came in contact with the foot of the bed, if the cold wood touched 
them they would fly up." He evidently had the contractions which 
are so clearly symptomatic of meningitis, and there was some constipa- 
tion, but no bladder trouble except atony. His neck " felt stiff," and 
he was occasionally dizzy. The loss of power in legs has gradually re- 
turned. 



240 DISEASES OF THE SPINAL MENINGES. 

Present condition. — The patient walks fairly, with no apparent impedi- 
ments. The skin is slightly hyper^esthetic ; no atrophy of any muscles ; 
has good muscular strength ; there is slight tenderness produced by pres- 
sure over the vertebrae between the scapulae ; muscular tension at back of 
neck, and some pain with movement ; slight distension of abdomen by 
flatus (he says this is a constant symptom) ; bladder and bowels in excel- 
lent condition ; some very trivial effort required to urinate ; no headache, 
but dizziness caused by looking upwards ; no loss of power in hands or 
arms ; no constricting band ; patient can stand with eyes closed. Co- 
ordination of delicate muscular acts unimpaired ; there are no twitchings 
at night left. I suggested the propriety of giving iodide of potassium in 
addition to ergot, which he had taken before. I also recommended the 
actual cautery. 

One of the characteristic symptoms of all forms of spinal meningitis 
is the rigidity of the spine, and there is an increased excitement of the 
tendinous reflexes which may be unilateral or bilateral. In the contracted 
limbs the percussion hammer produces a very energetic series of motor 
phenomena. The contraction of the muscles are usually aggravated 
when some voluntary eflbrt is made to overcome them, but the fingers 
of the patient may be often passively extended when his attention is di- 
verted. 

Causes. — According to Grisolle,^ spinal meningitis is much more 
common among men than women, and three-quarters of the patients are 
men ; and Calmiel considers it to be of much more frequent orgin before 
the thirtieth year than afterwards. Cold and intemperance favor its ap- 
pearance, but in the great majority of caseS; it is of spontaneous origin, 
and has occurred in epidemics, at least so say the earlier French writers.^ 
In 1837 an epidemic appeared at London, Versailles, Avignon, Metz, and 
Strasburg, and there were no atmospheric causes nor any influences dis- 
covered which could account for its appearance. It is probable, however, 
that the form of meningitis was cerebro-spinal, with the history of which 
we are now familiar. Alcoholic over-indulgence, syphilis, and injury, or 
vertebral disease, will account for the affection in some cases. Like 
locomotor ataxia it very often occurs among seafaring men who have 
fallen overboard, or have been obliged to stay aloft in damp, cold weather. 
Pott's disease has generally been supposed to have little to do with the 
etiology of the disease, but my own experience and that of professional 
friends who have had much to do with this class of cases, convince me to 
the contrary. In a case of this kind where I was enabled to make an 
autopsy, I found great thickening of the spinal dura, with fibrinous de- 
posits beneath that membrane and the bone, as well as some involvement 
of the nervous substance proper, which consisted in atrophy. Fractures 
of the spine, sometimes unrecognized, are attended by so much injury of 
these membranes as to give rise to symptoms which may be either sup- 

1 Op. cit. vol. i. p. 436. 

2 See articles in Memoires de 1' Acad6mie Nationale de Med., t. x., Eevue Medicale, 
and Gaz. Medicale, 1842. 



SPINAL MENINGITIS. 241 

posed to be due to myelitis or simple concussion, but which are undoubt- 
edly occasioned by an unrecognized fracture. Such a case has been re- 
ported by Mr. Hutchinson, in which the individual jumped from a height, 
alighting on his feet. 

Morbid Anatomy and Pathology. — The simple forms of spinal 
meningitis, that is to say the acute forms, present all the appearance of 
violent inflammatory action which we witness in cerebral meningitis : 
injection of the pia mater, serous or purulent effusions, together with in- 
filtration of adjacent' cellular tissues, more posteriorly than anteriorly, 
and perhaps some evidence of myelitis, but ordinarily the cord is healthy 
if the disease be uncomplicated. The region affected is more apt to be 
at the upper part of the cord, but there may be inflammation of the .me- 
ninges covering the dorsal or lumbar portions as well. It may be circum- 
scribed, as the result of pressure from displaced vertebrae, or fracture, and 
this limitation is more characteristic of pachymeningitis. The different 
membranes may be adherent to each other, and connected with the cellu- 
lar tissue in the vertebral canal. New growths beneath the dura mater 
are not common, but may be found sometimes between this membrane 
and the bones. In cervical pachymeningitis there is great thickening, 
and in old cases the nervous matter is compressed to such a degree that it 
is atrophied, and may be found to be hardly two-thirds its normal size. 
A lamellar arrangement of the dura mater exists, which is like that seen 
within the cranium, and the other membranes may be quite undistinguish- 
able from the dura mater, and consequently the. cord will be found en- 
circled by an almost homogeneous, tough, and thickened envelope. The 
cord, when the thickened membranes are removed, often presents an irre- 
gular contour, evidence of sclerosis being common. The lateral and 
posterior columns seem to suffer most. In the hemorrhagic form, there 
may be discovered encysted blood-clots which resemble those found in 
cranial hemorrhagic pachymeningitis. The nerve-trunks within the 
vertebral canal will be found to be covered by the same dense tissue, and 
the peripheral portions of the nerves are often atrophied. Syphilitic in- 
flammatory changes, alluded to by Buzzard,^ are sometimes present, with 
gummatous growths in the nerves proceeding from the cord. 

The following case illustrates the morbid anatomy of menin go-myelitis 
of a quite extensive character : — 

Idiot; Chronic Spinal Meningitis ; Lobular Pneumonia ; Circumscribed 
Acute Interstitial Nephritis; Chronic Cystitis. — D. A., set. 26, admitted 
June 22, 1877. No previous history of the patient could be obtained, 
except that she had been an inmate of the almshouse for three years pre- 
vious to admission, where she was confined to bed entirely. On admission 
patient was very much emaciated ; legs and thighs flexed. She was un- 
able to talk, but almost continually screeched, especially at night. Two 
days before her death she had a slight diarrhoea. On morning of June 
28 had elevated temperature, rapid pulse, and cough. Chest could not 

1 Syphilitic Nervous Affections, p. 70. 

16 



242 DISEASES OF THE SPINAL MENINGES. 

be satisfactorily examined, as she would not keep quiet. Moist rales 
were heard over entire chest. Patient became worse during the day, and 
died at 4 o'clock A. m., June 29, 1878. 

Autopsy twelve hours after death, made by Dr. Maxwell, the Curator. — 
Rigor mortis present ; body small, and very much emaciated ; thighs 
flexed and adducted, and the legs upon the thighs, and contracted. 
Feet oedematous. Bed-sore over sacrum and nates. Fingers and thumbs 
are flexed ; the cranium small ; round, low forehead ; hair dark ; com- 
plexion brunette ; eyes brown. 

Head. — Bones : calvarium circular ; antero-posterior diameter six in- 
ches ; deep Pacchionian depression on right side. Dura mater and sinuses 
normal. A little over three ounces of fluid in subarachnoid space. Pia 
mater over the convexity meshes is markedly elevated by oedema, and is 
opaque in latter situation ; it is also abnormally adherent over convexity, 
and in Sylvian fissure. Weight of brain and cerebellum 22 ozs. Exter- 
nally shows nothing except that the sulci are wide. Lateral ventricles 
are moderately dilated. Ependymse appear normal. Cerebellum weighed 
li oz. Brain-substance of cerebrum and cerebellum, gross appearances 
normal. 

Spinal Cord. — Adhesion in cervical region, betweeen dura mater and 
wall of spinal canal, so firm as to require section for its removal ; also 
another point in dorsal region. Adhesions between opposed surfaces of 
arachnoid in cervical region quite firm and general on the posterior sur- 
face; on anterior surface scattered filaments. On posterior surface of 
dorsal region a few filamentous adhesions. Dura mater in cervical region 
is appreciably thickened, especially the upper two inches. Pia mater cor- 
responding with these adhesions has brownish appearance, and is thick- 
ened. Veins of cord are filled. Nearly all dorsal portion of the cord is 
soft to the feel. Throughout cervical region the posterior and right 
lateral columns are to the feel firm and normal ; have bluish-gray color, 
with yellowish streaks. The dorsal portion of the whole cord markedly 
softened. Lumbar region and caudae equina, to gross appearances, show 
nothing marked. Dura mater surrounding vertebral foramina is thick- 
ened and adherent to sheaths of upper four or five inches of cervical 
nerves. Posterior long fissure of cord of the dorsal region obliterated by 
firm adhesions of pia mater. 

Prognosis. — The patient's chances are sometimes good, even in the 
chronic form. Charcot^ has cured one case of cervical pachymeningitis, 
and doubtless others have been equally successfal. In the great number 
of cases, however, a fatal termination is the rule. In the acute form death 
may occur in six days, but Tourdes and Chauffard have observed cases in 
which this termination did not take place till the fortieth or fiftieth day. 
In acute purulent meningitis the pus may make its way out, pointing ex- 
ternally, or forming an abscess in the muscular tissue of the back. Cham- 
pion has seen a case of this kind in which the purulent contents of the 
vertebral canal found passage through at the third lumbar vertebra, and 
formed an abscess in the spinal muscles. This, however, is exceptional. 
When the disease results from Pott's disease, or some other vertebral 
affection, it is perhaps possible, by mechanical treatment, to improve or 

^ Op. cit. 



SPINAL MENINGITIS. 243 

cure tlie patient ; and syphilitic forms, of course, are generally amenable 
to treatment. Death may occur from exhaustion, and is preceded by the 
formation of bed-sores, and evidences of a typhoid state. 

Diagnosis. — It is necessary to diagnose spinal meningitis of the acute 
form from myelitis,^ especially as these are the only two acute spinal mala- 
dies beginning with fever. The pain is much more severe in meningitis, 
and is aggravated by movement. The contractures and cramps are cha- 
racteristic of meningitis, and are not connected with uncomplicated mye- 
litis. Hypersesthesia, and exaggerated reflex irritability, and the lighter 
grade of the paresis (there rarely being paraplegia, and, if there is, it is 
quite late), are suggestive indications of meningitis, which should prevent 
any mistake. The chronic forms are of slow development, and all the 
symptoms increase progressively after their appearance, the paralysis 
being gradual and connected with contractures of the afiected limbs. The 
paralysis may not be bilateral, as is usually the case in syphilitic menin- 
gitis, and there is rarely any extension of the disease to a higher or lower 
level. In meningitis there are none of the atrophic tissue changes of the 
myelitis, but the chronic form may so closely resemble chronic myelitis as 
greatly to puzzle the diagnostician. The ansesthesia that belongs to mye- 
litis, however, is rarely present in meningitis ; and, if it should be, is a 
late and slight symptom. 

Tetanus may possibly be mistaken for meningitis, but such an error in 
diagnosis should be rare, the spasms of the former being much more 
general ; and, besides, the temperature variations are entirely different, as 
the thermometric rise in tetanus is unattended by any increase in the 
volume of the pulse ; while in acute meningitis the temperature and pulse 
are those of an inflammatory disease. 

Treatment. — The acute disease must be met with energetic treat- 
ment. Local abstraction of blood by leeches or wet cups is the first indi- 
cation. Rollet^ has used the cautery even in the last stages, applying it 
from the nucha to the sacrum, and with good effect. Chauffard^ has 
given opium in large doses in the early stages. I prefer, however, sup- 
positories of opium or belladonna, which seem always to relieve the pain, 
and are attended by the additional advantage of not deranging the 
stomach. Blisters applied on either side of the vertebral column, iodide 
of potassium, and mercurials (the former in large doses, even to the 
amount of a drachm thrice daily, beginning, however, with a minimum 
dose), are excellent remedies. In chronic meningitis I have repeatedly 
witnessed the beneficial effects of ergot, and the notes of the case I present 
will enable the reader to appreciate its immediate and powerful action in 
a very obstinate example. 

B. W., female, aged 24 years, single, domestic ; admitted to hospital 
July, 1875. 

^ By the use of this term I mean not only general myelitis, but those localized 
forms known as adult and infantile spinal paralysis. 
2 Memoires de I'Acad. Nat. de Med., xx. * Eev. Med., 1842. 



244 DISEASES OF THE SPINAL MENINGES. 

July 6. The accession of her trouble began about eight months ago, 
when severe pain in the lumbar region made its appearance. This was 
very intense, and seemed aggravated by the supine position. About ten 
days after this appeared, the abdomen became tender, and there were 
darting pains which extended about the body, radiating from the spine ; 
this abdominal tenderness continued for two weeks, and then disappeared. 
She was able, at the end of a month, to " go up stairs, and to move about 
the house." A few weeks afterwards she noticed a loss of power in the 
right leg and thigh, and next in the left ; and, a month later, she found 
it impossible to get out of bed in the morning. She said that her legs 
were hypersesthetic, and spoke of feelings of "pins and needles" in the 
soles of both feet. She says that she thought her trouble arose from a 
cold that she had caught when working in a damp place. All this time her 
pain was quite intense, and there has been no improvement. She has 
great difficulty in micturition, and is constipated. 

29i/i. Painted iodine on either side of the spine, and gave her gr. v. 
potass, iodid. t. i. d. 

Aug. 17. Her abdomen has been distended by gas for the last two 
weeks. Pancreatine 5ss t. i. d., and low diet. 

24^/i. This treatment has not diminished the size of abdomen. Ordered 
milk, rice, and beef- tea. 

^Oth. Lumbar pain very severe. She can hardly move at all, and is 
obliged to use crutches. Injections of tr. assafoetida. Charcoal and 
water fail to relieve the flatus. The abdominal distension is quite dis- 
tressing. 

31s^. To-day another injection of the same kind did no good. Insom- 
nia and great suffering, as the lumbar pain is severe ; prefers her bed, and 
lies on the left side. Chloral hydrate ;, potass, iodide. Increased convul- 
sive movements of legs. 

Oct. 9. At times she has localized pain over insteps of both feet, and 
pain on outer aspect of right knee. For the last five days slight numb- 
ness as far up as her knees. Legs have ''jerked" less for the last fort- 
night ; can move well in bed ; very slight power to move right knee ; 
frequent desire to urinate ; tympanites ; some colic, pain less in lumbar 
region. Pulse 126, small and irritable; temperature 101io°. Blisters 
every other night on either side of the spinous processes. 

24^/i. Abdominal pain lessened ; can move legs more freely ; numbness 
less. 

Jan. 20, 1876. Acidi nitromuriat dil. has relieved constipation, which 
has been a constant symptom. 

Feb. 7. 5ss. fl. ext. ergot t. i. d. 

19th. Ergot has had wonderful effect. Patient left her bed yesterday, 
and walked to the front door of hospital (about 50 feet) and back with- 
out fatigue. She steadied herself by taking hold of the bedsteads. Has 
discarded her crutches. 

25th. Walks well. 

March 15. Goes out of hospital. 

April 1. Discharged recovered. This patient was seen six months 
afterwards, and she had had no relapse. 

Ergot has acted beneficially in other cases which I have treated, and I 
am of the opinion that it is more valuable than any other remedy in both 
the acute and chronic varieties of spinal meningitis. The actual cautery 



SPINAL TUMORS. 245 

applied every other day should be faithfully used, and in addition we may 
employ setons at the nucha or lower down. Cod-liver oil and generous 
diet are to be prescribed, and every measure is to be adopted that will in 
any way build up the patient. Should we find vertebral disease, a suita- 
ble brace, or the plaster-jacket should be provided. The advantages of 
Sayre's suspension treatment can hardly be overrated, and I have repeat- 
edly seen very decided improvement follow the separation in this way 
of diseased vertebrae, and, consequently, removal of the pressure upon 
the nervous tissues. 

SPINAL TUMORS. 

The growth of tumors in the spinal canal or cord is of far less frequent 
occurrence than in the cranial cavity and brain, but when tumors choose 
this locality their presence is to be much more easily diagnosed. 

The varieties of spinal growths are just as numerous as those found in 
or about the superior part of the cerebro-spinal axis. They may be of 
any of the forms I have named in speaking of cerebral tumors, but those 
usually met with are the following : — 

Syphilomata. 

Fibromata, attached to the meninges, or in the substance of the cord. 

Tuberculous (rarely). 

Myxomaia. 

Sarcomata. 

Parasitic growths are seldom found, and the other forms which have 
been spoken of in our consideration of brain-tumors are equally 
uncommon. Exostoses give rise to many obscure, but none the less inter- 
esting symptoms, while sarcomata are occasionally to be found attached 
to the inner surface of the dura mater or other meninges. 

Spinal tumors are of slow growth, and of course the appearance of 
symptoms is consequently gradual and insidious. 

Symptoms. — The first indications are expressions of irritation, and 
as a result there will be localized pain, and various disturbances of 
motility dependent upon the aberration of that part of the cord which is 
the seat of the tumor. Our knowledge of physiology of the cord will 
enable us to appreciate that disturbances in various parts will be followed 
by symptoms of paiu,^ hyperkinesis, akinesis, or muscular contractures 
expressive of involvement of the posterior, anterior, or lateral columns, 
but there is usually no such possible localization, as the growth generally 
impinges upon large tracts and works wholesale mischief Compression 
is followed by still more pronounced symptoms than those attendant upon 
simple irritation. And there may be complete paralysis and atrophy, 
with muscular contractures of the members either of the upper or lower 
extremities. Should the tumor be situated high up in the cord, the mus- 
cles at the back of the neck may be the seat of contractures, and those 
of the face and neck may even suffer ; if the tumor be seated lower down, 

^ Reynolds considers that pain in the back is more intense with carcinoma than 
with tubercular or other growths. 



246 



DISEASES OF THE SPINAL MENINGES. 



the bladder and rectum may also become involved, as in some otber forms 
of spinal disease. 

Among the early symptoms may be mentioned the constricting band 
which is connected with neuralgic pains that shoot down the legs. These 
indicate irritation of the posterior columns and nerve-roots. There is also 
a certain amount of painful rigidity of the spinal column. Should the 
anterior column and nerve-roots be subjected to the irritating presence of 
a tumor, the consequence of such trouble will be convulsive local spasms 
and increased reflex excitability. Vomiting, dizziness, and pupillary dila- 
tation are mentioned by Jaccoud as evidences of tumor situated in the 
cervical region, while nystagmus and strabismus are also occasional ex- 
pressions of a growth so located. 

The paralysis which follows increased pressure is not always equal, one 
limb being more feeble than another ; or there may be hyperkinesis on 
one side, and paresis on the other. 

Unilateral irregular troubles, both of motility and sensibility, are the 
rule. There may be limited and well defined anaesthesia and analgesia will 
be found on the side opposite the lesion, while the paralysis may be the 

Fig. 36. 

MS S M 




striking symptom on the side of the tumor. This may be explained by the 
diagram of Radcliffe, which I have slightly modified. Supposing that Fig. 
36 represents a segment of gray matter, we will consider that S S ' repre- 
sent sensory fibres of a nerve-root, and M M motor fibres. The sensory 
fibres decussate, S going to one side of the body while S' goes to the other. 
M and M' both leave the cord on opposite sides. A tumor, pressing upon 
either lateral half of the cord, such as " I," may simply paralyze motion on 



SPINAL TUMORS. 247 

the same side, while sensation remains unaffected, and both sensation and 
motion are intact on the other. If deeper pressure is made, supposing 
" II " to represent the tumor, not only would motion be paralyzed on 
this side, but sensation on the other. If a tumor such as " III " should 
impinge at the decussation of the sensory conductors, we might expect 
total abolition of sensation on both sides, while there would be no paraly- 
sis of motion. A tumor such as '' IV" would paralyze sensation on both 
sides, and motion on one. When we find that there is crossed spinal 
paralysis, one arm perhaps being involved with the leg of the opposite 
side the lesion undoubtedly occurs in two points of the motor spinal track 
at a place above the decussation and below. 

Reflex excitability is ordinarily increased in the limbs below the lesion, 
but it is stated that, when the inferior part of the lumbar region or the 
Cauda equina are destroyed, reflex excitability is abolished after a period 
of six days, and that then the muscles begin to atrophy. Jaccoud ^ 
says : " There is here a new application of the law I have endeavored to 
make clear. As long as cerebral influence only is deficient in the infe- 
rior members, the reflex and electric motility and nutrition of muscles are 
intact, but when the spinal influence is in default these properties are 
abolished." 

A case which may be detailed because of its interesting morbid appear- 
ances and which during life seemed to refute this assertion is the follow- 
ing, but after death an additional tumor was found higher up, which 
might have suspended cerebral influence, and still have left a portion of 
the cord capable of giving rise to reflex movements when irritated ; but 
in some respects the case still renders what Jaccoud has said somewhat 
doubtful, as the question arises whether the larger tumor did not ante- 
date the smaller, and whether the original paraplegia did not take place 
before the growth of the smaller tumor destroyed the cord. The patient 
entered the Epileptic and Paralytic Hospital September 18, 1872, and 
was examined by Dr. Janeway, Dr. Seguin, Dr. Mason, and myself, and 
the very thorough autopsy was made by Dr. Maxwell. 

P. K., aged 30 years; occupation, painter; habits, intemperate. Inva- 
sion of the disease, five years ago. Relations to other diseases, disease of 
the spine. Seat of paralysis, lower extremities. Control of sphincters, 
very poor. Voluntary movements, imperfect. Sensibility, good. Speech, 
good. Hearing, good. 

Patient denies venereal disease, and no indications of it are found on 
examination. He states that ten years ago, after an attack of smallpox, 
he noticed a pain in the lumbar region, slight and irregular in occur- 
rence. 

Accompanying this pain he has had frequent and uncontrollable desire 
to go to " stool," and to make water, but could not do either to his satis- 
faction. This all continued for about five years, when he noticed that he 
was gradually losing control over his lower extremities, and in five months 
was completely paralyzed. 

1 Op. cit., p. 352. 



248 DISEASES OF THE SPINAL MENINGES. 

Says the lefc lower extremity remained unaffected the longest, and in a 
short time this a^so became as weak as the right. Has no control over 
bowels, and has but little control over the bladder. Physical examina- 
tion reveals a slight degree of right lateral curvature, and a marked 
prominence in lumbar region, and tenderness on pressure at a point cor- 
responding to fifth lumbar vertebra. These signs seem to point to lum- 
bar abscess, as there is slight fluctuation, and the cachexia of patient is 
decidedly indicative. 

Both lower extremities are much atrophied, soft, and flabby. Patient 
very ansemic. Prescribed iron and quinine. 

October 9. Patient since examined by Dr. Seguin, who says the ab- 
scess is over a point corresponding to upper third of sacrum, instead of 
last lumbar vertebra, as was first supposed. 

14th. At the age of thirteen was struck in the small of the back with 
a stick. No phthisis. At beginning of trouble he had severe pains in 
dorsum of feet, with swelling and short lancinating pains. Pains in back 
part of the thighs, in loins, and about the sides of pelvis. No inconti- 
nence of feces. Curvature began about a year later than the commence- 
ment of paralysis. When limbs were extended they were agitated by 
clonic spasms, and increased pain in feet. As paralysis increased pain 
diminished, although diminution was not noticed until after contracture. 
In last two years no material change has taken place. Pain at irregular 
intervals, and occasional spasms in legs at night. Has had from the first 
a feeling of coldness, but never any numbness. Voluntary movements 
at hip-joint quite free. Knees flexible at an acute angle. Extension 
and flexion possible in both knee-joints to such an extent as to bring legs 
at right angles to thighs. No sign of voluntary movement below knee- 
joints. Passive movements free at hip-joints for extension, which is con- 
siderably restrained at knee-joints. Flexion free, extension beyond right 
angle hindered by tension of flexor muscles of thigh. More free at 
ankle-joints and toes ; the thighs are somewhat wasted, but not truly 
atrophied. Left measures 371 centimetres ; right, 32 centimetres. 

The legs show extreme atrophy, most marked on right side. Left calf 
measures 23 J centimetres; right, 21 J centimetres. The feet are not 
oedematous. The integument over lower half of tibia is apparently hyper- 
trophied, feels elastic, does not pit on pressure ; the appearance is like that 
of oedema. The bones do not seem to be enlarged. 

When he urinates he appears to empty the bladder at once, but does 
it with difficulty. 

Sensibility decidedly lessened below knee ; slight impairment of feel- 
ing on posterior aspect of thighs. Sensibility much impaired below 
knees. Impressions of pain are perceived less acutely than normal at 
top of right foot ; less acutely on left foot. Pricking not felt on left toes ; 
slightly perceived on right toes. 

Claims to perceive pressure of hands on both feet. On irritating soles 
of feet, slight involuntary movements are caused in thigh muscles. Legs 
and feet markedly cold. On left foot has ingrowing nail, with ulcerated 
external matrix. The right toe was seat of ingrowing nail, with ulcera- 
tion, some months ago. Lower limbs perspire easily when warmed in 
bed. Very feeble response to faradic current on tbighs ; feeble reaction 
manifested. No response in leg muscles. Lower lumbar region presents 
a rounded tumor, about 21 inches in diameter, projecting about an inch, 
and situated wholly over sacrum. The last two lumbar vertebrae are 



SPINAL TUMORS. 249 

unnaturally prominent. Moderate pressure produces no pain in tumor ; 
several large veins lie over tumor, which is elastic to feel, and gives an 
obscure deep fluctuation. 

Deep pressure in left iliac region produces but slight pain. The finger 
reaches a tumor deep in abdomen. Examination by rectum shows a re- 
laxed sphincter ; the finger meets with an apparently large promontory 
of sacrum, which is moderately elastic ; some fluctuation. There is quite 
surely a tumor involving the anterior surface of sacrum. Pressure of 
finger upon pelvic tumor does not afiect external dorsal swelling. 

Patient remained in the hospital for a year after this, and finally died 
of exhaustion. 

Autopsy thirty-one hours after death. Rigor mortis passing ofi*. Ab- 
domen of greenish discoloration. Lower extremities contracted. Left 
foot slightly oedematous ; muscles of extensors atrophied ; commencing 
decomposition in superficial veins ; large bed-sores over sacrum. 

Brain. — P. M. decomposition ; P. M. imbibition along vessels. 

Stomach and Intestines are apparently normal. The pelvic cavity was 
filled by a moderately firm, elastic, ovoid tumor, extending upward out of 
the pelvis as far as lower border of third lumbar vertebra ; the psoas mus- 
cles flattened, and spread out over its upper and outer border on either 
side. Aorta and inferior vena cava raised and flattened by the upper end 
of the tumor ; the external iliac vessels raised from their normal situation 
and course over its lateral borders. All of above-mentioned vessels 
empty ; the ureters are over the upper border of the growth, and are 
tightly stretched and flattened. 

Bladder contracted ; fundus raised out of pelvic cavity ; muscular tra- 
becule flattened ; mucous membrane pale around openings of grandular 
follicles. 

Prostate gland elongated, flattened, and atrophied from pressure. 

Rectum raised and pressed against posterior left lateral wall of bladder. 
The growth had its origin behind peritoneum. 

The tumor has destroyed the whole sacrum, except a small piece of its 
lower end, and a few small thin plates, from here and there, on the sur- 
face of its posterior attachment ; the fourth and fifth lumbar vertebrae 
were wanting, except portions of laminoe and spinous processes ; the body 
of third has in its lower border a large concave cavity. 

The tumor was also attached to the lateral wall of the pelvis ; the 
articular surfaces of the ilia eroded ; the right most destroyed. During 
its removal large cavities were opened, from which a thin, yellowish, viscid 
fluid escaped, more or less colored with blood. After removal, the tumor, 
with bladder, prostate, and portions of rectum, weighed five pounds ; 
measured in long diameter twelve inches, transverse six to seven inches. 
In laying it open on posterior attached surface, the tumor is composed of 
large trabecul^fi and solid portions inclosing areola, which contained the 
fluid above mentioned. 

The surface of the trabeculse was covered with small and large villi, 
projecting into the cysts ; the general color was yellowish or yellowish- 
brown ; in certain portions hemorrhagic. These hemorrhagic patches are 
softer than the yellow " consistency," and there were solid portions, where 
it was quite firm. Microscopic examination showed the histological struc- 
ture of the tumor to be a myxo-fibroma-cavernosum. 



250 SPINAL HEMOREHAGE. 

Spinal Cord. — A small secondary tumor, about two inches above its 
lower end on left side, behind origin of anterior roots of spinal nerves. 
This tumor is about three-quarters of an inch by half an inch wide, ovoid, 
reddish, and shining, gelatinous, and attached to the " pia mater." The 
Cauda equina has been destroyed, except a short portion of the origin of 
the nerves composing it ; the whole cord, but especially the anterior half 
below cervical portion, softened, presenting numerous varicosities. 

The secondary symptoms of spinal tumor are those which are generally 
known as " compression symptoms." All the phases of secondary de- 
generation follow, and after a variable time, the patient's taking off may 
occur from myelitis and exhaustion. 

Causes. — The existence of the tubercular or syphilitic cachexia, the 
indications of former or coexisting syphilitic symptoms, and the history of 
the patient, may throw some light upon the spinal condition ; but, after 
all, we know very little about the etiology of spinal or other tumors. 
Spinal growths are rarely found, except in adult life. 

Morbid Anatomy and Pathology. — Syphilitic deposits are 
found in the spinal substance between the meninges and about the nerve- 
roots. The exudation resembles that found in the brain and other organs. 
The site of these deposits is chiefly about the circumference of the cord, 
and is rarely central. Tubercular deposits may affect the entire cord and 
its covering, but have been met with in the majority of instances in the 
gray matter. Jaccoud says that they are nearly always found in the 
gray matter of the lumbar enlargement. Tubercles may be found co- 
existing in the cord and brain. Myxomata are found in the cord much 
more often than in the brain, and are attended by separation of the 
nerve-fibres and great mechanical destruction. Cancerous growths 
may and usually do spring from the vertebrae, and are of a fungoid 
character. Secondary degenerations are to be found in certain cases, as 
well as aneurisms, organized clots, cysts, and other evidences of previous 
disease. 

Diagnosis. — It is not an easy matter to distinguish the symptoms 
which attend spinal tumor from those of some of the other spinal diseases. 
"We should bear in mind, however, that the indications are slowly ex- 
pressed ; that the paralysis is irregular ; that one group of muscles may 
be affected at first, and then others ; that the degree of lost power is not 
the same on both sides of the body ; and, also, that perverted sensation 
is not the same over the two sides ; that, usually, there are contractures 
of the limbs which need not be preceded by atrophy ; and, finally, that 
pain is a symptom which is very constant. A diagnostic point alluded to 
by Ley den is that certain movements increase the spinal pain as the tumor 
is compressed. 

Prognosis. — I have never witnessed a recovery from spinal tumor 
unless the character of the growth was syphilitic, and doubt very much 
whether a cure has ever been effected. It is impossible to limit the dura- 
tion of disease which depends so much upon the character of the morbid 



SPINAL HEMORRHAGE. 251 

growth. Patients may last for eight or ten years ; or, on the other hand, 
they may live a very short time, should the tumor be cancerous. Death 
usually occurs by pneumonia, uraemia, or some debilitating disease. 

Treatment. — If syphilis be suspected, we are to give very large 
doses of the iodide of potassium ; or, we may administer the biniodide of 
mercury in combination with this salt. In other states, supportive treat- 
ment or counter-irritation offers a feeble hope of relief. Morphia or 
muscarin may be injected hypodermically for the relief of pain. 

SPINAL HEMORRHAGE. 
meningeal; central. 

Synonyms. — Hsematorrhachis ; hsematemyelie (OUivier). Spinal 
apoplexy. 

Under this head we may consider the effusion of blood into the spaces 
between or under the meninges of the cord, and the effusion of blood into 
the substance of the cord itself. . 

Symptoms. — Very often the first intimation of the rupture is a sud- 
den loss of powder, and consequent inability of the individual to stand. It 
may, on the other hand, be of gradual development, the symptoms ap- 
pearing in groups, one after the other. The resulting paralysis is gene- 
rally complete, and the patient loses both motor power and sensibility, as 
well as control over the bladder and bowels, accompanied by a number of 
slowly-developed symptoms, with diminution of reflex excitability, al- 
though the latter may be exaggerated in some cases should the hemor- 
rhage be small and between the meninges. The abolition of muscular 
power may vary in proportion to the gravity of the hemorrhage, and if 
it be small the patient may ultimately .recover, and eventually present 
no indications of his loss of power. I have never seen a fatal termina- 
tion before the end of several days, and doubt if such could be the case 
unless the hemorrhage should occur at a very high point, involving a 
number of the intercostal nerve-roots ; but even this is improbable. Of 
course much depends upon the site of the ruptured vessel. If the upper 
part of the cord or the medulla be affected, then an immediate and fatal 
termination is a natural result. Meningeal hemorrhage is characterized by 
more pronounced symptoms of muscular rigidity, or by convulsions, 
which may be of a tetanic character. If the hemorrhage has taken place 
above the fourth or fifth dorsal vertebra, it is common to find obstinate 
priapism and intestinal disturbances, giving rise to flatus, these resulting 
from paralysis of the splanchnics ; if it be extensive, there may be para- 
lysis of motion and sensation from pressure exerted upon the cord, and 
pain and spinal tenderness are also quite marked symptoms, and in uncom- 
plicated cases there is cutaneous hypersesthesia. There is commonly no 
loss of consciousness in either variety, but when the effusion takes place 
in the medulla there may be conditions akin to epilepsy. In this case, 



252 DISEASES OF THE SPINAL MENINGES. 

however, effusion would be very small, and the region affected would be 
near the circumference. 

Causes. — Spinal hemorrhage is usually the result of a traumatism, 
but may proceed from various debilitating maladies and some of the 
zymotic diseases, smallpox playing occasionally a part in the etiology. Al- 
coholism, and other conditions in which the cord is congested, may pre- 
dispose ; or the hemorrhage may result from the rupture of an aneurism 
in the vertebral canal, such as occurred in Laennec's case. It very rarely 
takes place as a secondary accident in tetanus, so that it can be recognized 
before death ; but at the post-mortem examination such pathological evi- 
dences may be occasionally observed. Traumatisms undoubtedly most 
frequently produce this condition ; and falls, blows upon the back, or 
concussion following a fall upon the feet, enter into the etiology. It 
rarely occurs after middle age, and men are more often the victims than 
the other sex. It occurs in the course of myelitis, but again it may 
happen without any trace of inflammatory trouble to be discovered after 
death ; and, in some instances, there is no history of injury. Such a case 
undoubtedly resulted from sudden congestion at the menstrual period, 
and is reported by Goldammer^ : — 

" The patient, a girl of about sixteen years, was suddenly attacked with 
a severe pain in her back between her shoulders, which soon passed over 
to her right, and after a while to her left arm. She also noticed a pain 
in the pit of her stomach, and found somewhat later that she could not 
move her right leg. Having been sent to the hospital, the examining 
physician found complete paraplegia, complete anaesthesia up to the ma- 
millj?e, and paralysis of the bladder, while the reflex action of the lower 
extremities was still intact ; her temperature was normal, pulse 80 ; did 
not show any brain symptoms, but complained of pain in both arms. A 
few days afterwards the abdominal and dorsal muscles proved to be par- 
alyzed, and percussion of the spinous processes of the dorsal vertebrae 
caused her pain. The pulse was 96 ; her bowels moved only when dras- 
tics were given her. A slimy discharge from her vagina was noticed. 
The case was considered as hemorrhage into the spinal cord below its cer- 
vical enlargement. The treatment consisted in local depletion, in the 
methodical use of the ointment of mercury, and in the use of drastics. 
The patient, having improved in general very little, died from decubitus 
about a year after the attack. The most noteworthy observations made 
on autopsy are the following: About one inch below the cervical enlarge- 
ment of the spinal cord there seemed to be a compressure. A cross sec- 
tion through this part showed that its original diameter was reduced very 
much, and that the right lateral column and the adjacent parts of the an- 
terior and posterior columns, as well as the gray substance between, were 
occupied by a rusty brown substance of callous consistence. The micro- 
scopic examination of this proved that it was formed of connective tissue 
inclosing fatty matter, crystals of haematoidine and a granulated brownish 
pigment ; the vessels in this part had undergone fatty degeneration, their 
walls were thickened, and contained brown pigment ; 7io nervous elements 
could be found in this substance; its entire length was about one tenth of 

1 Virchow's Archiv., Jan., 1876, and abstract in Med. News. 



SPINAL HEMORRHAGE. 253 

an inch. The adjacent parts of the medulla were not degenerated by sof- 
tening ; only a ■ few rusty stripes and a yellowish color were noticed on 
their examination ; the whole remaining cord was found to be intact. 
As no symptom speaks for myelitis as a causal element in this disease, it 
could only be caused by an effusion of blood into the substance of the 
cord : the latter probably had been provoked by suppression of the 
menses, for the heart and the vessels, especially those of the spinal mar- 
row, were intact, and no injury had occurred to the patient. It is true 
that she stated she never had had her catamenia nor noticed any moli- 
mina, in spite of her age and bodily development. There were, also, no 
signs of menstruation noticed during her sickness. But there was revealed 
by autopsy the presence of a corpus luteum of the size of a pea, and cer- 
tainly of long standing ; and a slimy excretion from her vagina was 
observed a few days after the attack. These facts favor strongly the 
above-mentioned suggestion." 

A cause alluded to by Erb is the disturbance of the balance of pressure 
within and without the cord. As a cause of this kind may be mentioned 
the sudden spinal congestion that takes place when an individual goes 
into a caisson or other place where compressed air is used. Dr. A. H. 
Smith, some years ago, alluded to a form of disease which occurred 
among the men at work in the caissons of the Brooklyn bridge. 

Morbid Anatomy. — Central : hemorrhage takes place into the up- 
per part of the cord more often than in any other locality, but the lumbar 
and dorsal segments may also be its seat. The gray matter is naturally 
more frequently the seat of hemorrhage than the white, and when pre- 
ceded by myelitis or injury it will be generally more extensive than in 
the latter. If the hemorrhage be profuse, we will find that the cord is 
enlarged at the point where the escape of blood has taken place, and that 
it has a doughy feel. Hemorrhage into the meninges may be sometimes 
associated with an intracranial condition, the blood escaping from a cere- 
bral vessel, flooding the ventricles, and passing down into the spinal cav- 
ity. Various meningeal diseases may terminate in this way, as well 
as spinal congestion and tetanus, and occasionally spinal tumors and 
vertebral disease give rise to such an efi'usion of blood. Old cysts have 
been found in the cord in some cases, but their existence is comparatively 
rare, and when met with they present the same appearance as is seen in 
the brain, though of course they are much smaller. In meningeal hemor- 
rhage, the coverings of the cord are red and suffused, and perhaps opa- 
lescent and thickened, and there is possibly some meningitis with sero- 
purulent collection ; the effused blood may be found as a semi-organized 
clot, and presents, according to the time of existence, changes of color of 
varying dej^th. The size of the clot may vary from a few millimetres 
in diameter to a much larger size. In some instances the pia mater is 
torn so that there is an escape of blood into other parts. Occasionally 
the condition which favors the development of spinal apoplexy may lead 
to cerebral accidents of the same character, and evidences of such trou- 
ble may be found to coexist. Evidences of secondary myelitis are quite 
common about the lesion. 



254 DISEASES OF THE SPINAL MENINGES. 

Diagnosis. — The symptoms must be distinguished from paraplegia 
due to myelitis, and from those of cerebral hemorrhage, which may, as 
Brown-Sequard has lately shown, be produced. In the former there are 
primary symptoms which I will discuss in speaking of myelitis, and in 
the latter there is usually some affection of consciousness, and some dis- 
turbance of speech. This latter variety of disease (cerebral paraplegia) 
is so anomalous, however, as to have but little weight as a condition to be 
excluded. The subsequent effects of such a hemorrhage, paralysis, con- 
tractures, etc., may be confounded with several chronic conditions. Among 
these are spinal tumors, adult spinal paralysis, and ataxia. The first 
is connected with decided hyperkinesis, is of gradual development, and is 
accompanied by slowly appearing symptoms. Antero-spinal paralysis or 
adult spinal paralysis is ushered in by fever and unattended by any loss 
of sensation or incontinence, and the atrophy is rapid. Locomotor ataxia 
is symptoraatized by increased electric contractility, by no paralysis, by 
disturbance of co-ordination, by absent knee-phenomenon and by optic 
nerve and pupillary changes. 

Prognosis. — If the hemorrhage takes place in the meninges or in 
the lower part of cord, the prognosis is perhaps better than if its seat is 
in the cervical or dorsal segments. In the first instance the patient may 
live some time or ultimately recover, but in the latter the probability of 
sudden or early death is almost certain. Grisolle^ says "Spinal hem- 
orrhage runs a rapid course. A single patient has survived forty days ; 
the majority, however, succumb at the end of several days, by suspension 
of respiration. Among others death is hastened or produced by the de- 
velopment of bedsores. Nevertheless, spinal hemorrhage is not necessa- 
rily a fatal condition." He refers to a case observed by Cruveilhier, and 
states that this is the only cure of which he has known. Erichsen,^ how- 
ever, has reported recoveries which have taken place in cases which were 
of traumatic origin ; so the prognosis is perhaps not so bad, after all. 

Treatment. — The early treatment of spinal hemorrhage should con- 
sist of cold applications to the spine, perfect quiet, and rest. Subse- 
quently ergot and belladonna will be of great benefit. The former may be 
injected hypodermically in the form of its extract, rather free doses being 
used which should be repeated frequently. Five or even ten grains may 
be used. Iodide of potassium in full doses does good sometimes. Blis- 
tering and leeches to the painful point in the back are next in order, and 
later on the actual cautery is the most serviceable external agent. 

^ Grisolle, Path. Interne, vol. i. p. 659. 
^ On Concussion of the Spine, etc. 



SPINAL HYPERJEMIA. 255 



CHAPTER VIII. 

DISEASES OF THE SPINAL COED. 

SPINAL HYPEREMIA. 

(a) spinal congestion; (b) subacute spinal hyperemia. 

Two varieties of spinal hypersemia exist : one of sudden origin, and of 
a sthenic character, which I prefer to call Spinal Congestion ; the other 
of slow progress as compared to the first, and characterized by aceumula- 
tion rather than congestion, which I will speak of as Subacute Spinal 
Hyperoemia. 

SPINAL CONGESTION. 

This first variety, which has been excellently described by C. B. Rad- 
cliffe/ is not so common as the latter, or at least such has been my ex- 
perience. It is apparently a serious condition, and may somewhat puzzle 
the incautious observer who may mistake it for some one of the organic 
diseases ; but it has certain distinct features which do not belong to the 
organic neuroses, and I think there should be no difiiculty in making a 
diagnosis. 

Symptoms. — The following may be the symptoms of an attack of 
Spinal Congestion. The patient probably attracts the notice of his friends 
by telling them that he cannot get out of bed, that " he feels as if he were 
a lump of lead," or that his " legs and arms are made of wood." He can- 
not move, and complains repeatedly of his utter weakness ; he sighs, and 
may complain that the room is close, and ask to have a window opened ; 
he is able to appreciate any warm substances that may be applied to the 
surface, and very acutely feels pinching or the prick of a pin. The legs, 
he says, seem very cold, and he requires extra covering ; he has backache 
and pains, which run down the back of the thighs, but pressure does not 
aggravate the pain in the back, which is only relieved by lying upon the 
side or belly. His mind is clear, but he is restless, suffers for want of 
sleep, and is extremely uncomfortable. The functions of the bowels are 
perhaps interfered with, there being constipation ; but there is never in- 
continence of urine or feces. The patient becomes paralyzed, and such 
par^ysis is rather sudden, and may take place during the night, or per- 
haps more gradually after the appearance of pain and the other symptoms 
just mentioned. Reflex action is abolished, and electro-muscular contrac- 
tility is increased. 

^ Article in Eeynolds's System of Medicine, American edition, vol. i., p. 942. 



256 DISEASES OF THE SPINAL CORD. 

Radcliffe calls attention to the wasting of tlie muscles, but I have never 
seen more than the general atrophy which would occur from disuse of the 
lower extremities, for the patient may sometimes lie in bed f6r months 
before he regains the lost power. The duration of the attack rarely ex- 
ceeds six weeks, but there is a possibility'of a second attack. The paraly- 
sis is generally paraplegic, though it may be irregular in its onset, one leg 
or arm being aJSfected before the other, and in some cases it is general. 
The spinal pain seems to be increased by warmth, and the patient will 
feel the ice-bag to be very grateful after lying upon his back for a long 
time on a warm bed. These pains are as a rule unaffected by movement, 
which is not the case in meningitis. Bed-sores as a feature of the disease 
are never seen, and for this reason no suspicion of transverse myelitis 
should arise. 

SUBACUTE SPINAL HYPERiEMlA. 

Symptoms. — The expressions of this condition are very slowly mani- 
fested, and are very often mistaken for those of the opposite condition — 
ansemia of the cord. Tingling and heaviness of the limbs may distress 
the patient, and render him disinclined to take exercise or remain stand- 
ing for any length of time, and much of his want of energy may be mis- 
taken for laziness. These symptoms are especially disagreeable towards 
night in those who have walked much during the day, and there is an 
uneasy, tired feeling, which is only relieved by change of position ; and 
the patient seeks in vain for a comfortable place to rest his weary limbs, 
and only finds it when he lies upon his bed or sofa. There may be cuta- 
neous anaesthesia, and occasionally hypersesthesia, but these sensory 
troubles are by no means common. There may also be the "constricting 
band," which is so usually suggestive of inflammation, and there are 
vague undefined pains in the thighs, legs, and back, which are extremely 
distressing. The temperature is lowered, and there may be the same op- 
pressed breathing which -is such a marked feature of the acute variety. 
Decided paresis is rare, and, if it should take place, it is nearly always 
paraplegiform, and not general, as it may occasionally be in the acute 
variety. Should this be the case, we will find the same impaired condi- 
tion of reflex excitability and normal electro-muscular contractility which 
characterizes the more active variety of spinal hypersemia. The tendency 
of the disease is to disappear under proper treatment, and in its worst 
forms is neither a grave nor lasting trouble, and should not be looked 
upon with alarm. 

Causes. — Women seem to be more subject to the first form than men, 
and this is probably owing to irregularities of the menstrual condition. 
Uterine conditions, symptomatized by dysmenorrhoea or amenorrhoea, may 
be, and often are, its sole causes. Among men, the long continuance of 
the erect position seems to favor the gravitation of blood, and hypostatic 
hypersemia of the spine is thereby induced. A few years ago I satisfied 
myself that the maintenance of the erect posture for a long-continued 
period resulted in a great deal of mischief. My investigations were chiefly 



SPINAL HYPEREMIA. 257 

among car-drivers, who were compelled to stand upon the platform of the 
city railroad cars for a period of from fourteen to sixteen hours daily. 
Spinal congestion, varicose veins, and other vascular changes were com- 
mon and serious results ; and the spinal troubles were only relieved by a 
long rest. Venery, alcoholic intemperance, and malaria are often causes 
of spinal hypersemia ; and suppression of any bloody discharge, such as 
the menses, or that from haemorrhoids, will be apt to be followed by more 
or less spinal hypersemia. Among the more serious causes of spinal hyper- 
semia may be mentioned the fevers. The spinal congestions which usher 
in some of the exanthemata are symptomatized by back pains, etc., and 
do not properly come under this head for discussion ; but there are condi- 
tions which play a most important part in the etiology of spinal conges- 
tion. The malarial cachexia very frequently induces a condition of spinal 
hypersemia which misleads the observer, and the true cause may be lost 
sight of under the periodic character of the painful exacerbations. This 
we should take into account if there be any suspicion of malarial poison- 
ing. I have seen many cases of very decided subacute spinal hypersemia 
which followed intermittent fever. The disease had become masked to 
some degree, so that no chill was complained of; but the individual suf- 
fered more at some parts of the day than at others, and, in one case of 
this kind, there was some loss of power, which was increased daily at a 
certain hour, and never seemed to disappear entirely. 

Morbid Anatomy and Pathology. — What I have said in speak- 
ing of cerebral hypersemia may be referred to in explanation of the ap- 
pearances met with in spinal congestion. The gray matter will be found 
to be quite dark, and the vessels are usually enlarged. The white matter 
is often of a pinkish hue, and there may be areas of hypersemia which 
are localized ; or the suffusion may be general. Microscopically examined, 
the cord will be found to have undergone very slight changes, and they 
may consist only in increased vascularity, enlargement of capillaries, and 
perhaps some exudation beneath the vascular sheaths. The vessels of 
the meninges are engorged, and there are to be observed small ecchy- 
mosed spots, or occasionally an eflPusion of serum. The symptoms of the 
disease result from pressure upon, and irritation of, the nervous elements ; 
and the violence will depend upon the site of the most decided hypersemia. 
The gray substance, when subject to pressure from distended vessels, gives 
rise to the pain in the back, and cutaneous hypersesthesia, as well as the 
spasmodic movements which symptomatize the aggravated forms. Spinal 
hypersemia is directly induced by blood defects and disease of other organs, 
and it is favored by the anatomical structure of the parts concerned. 
The tortuous course of the veins, and the absence of valves, are, accord- 
ing to Jaccoud, among the latter. The stasis of blood in their interior, 
which follows forced respiration, such as must b^ caused by violent exer- 
tion, or by disease of the thoracic and abdominal organs which to some 
degree arrests the return of venous blood from the cord, favors hypersemia. 

Diagnosis. — Spinal meningitis, myelitis, and spinal irritation are the 
diseases with which it may be confounded. 
17 



258 DISEASES OF THE SPINAL COED. 

1st. The spinal pains of meningitis are increased, as has been shown, 
by movement, which is not the case in spinal congestion, and there is a 
muscular rigidity in the first-mentioned disease which does not exist in 
this. 

2d. Myelitis di\&QY^ from spinal congestion for the reason that complete 
anaesthesia, wasting, loss of electric contractility and sensibility, reflex- 
excitability, incontinence of urine and feces, and bedsores, belong to the 
former. 

3d. Spinal irritation (anaemia?). The spinal tenderness is increased 
by pressure in anaemia, and there is no cutaneous tingling. There are 
troubles of other organs, and generally a variable amount of hysteria. 

Prognosis. — The chances for recovery are very good, provided active 
measures are at once taken to reduce the fulness of the spinal vessels. If 
the condition becomes a chronic one, even then much may be done to im- 
prove the abnormal state of the circulation. In many cases, however, it 
precedes myelitis, particularly when it takes the slow course which I have 
described as subacute spinal hypersemia, or it may lead to atrophy ; but 
this tissue-change is more directly induced by spinal anaemia. 

Treatment. — The local application of cups, counter-irritants, and 
cold may all be practised ; and, in addition, we may use either hydro- 
bromic acid, the bromides, or ergot, in full doses ; or belladonna till 
some of the toxic eflects are produced. It is never well to prescribe 
alcohol, strychnine, or iron in these cases, or any agents which in- 
crease central irritability, and I have witnessed disastrous effects from 
their use. The Turkish bath is, I think, one of the best adjuvants to 
these forms of treatment. As a local application to the spine, I have di- 
rected the patient to procure a strip of adhesive plaster, which should 
extend from the lower cervical vertebra to the sacrum. This is to be 
warmed and dusted with red pepper, and then applied to the back. It is 
a very excellent form of counter-irritant, and may be worn for some time. 
The cups may be wet or dry, according to the severity of the case, al- 
though I prefer the former. Should there be any pronounced symptoms, 
these are to be used two or three times a week. It must be borne in mind 
that general treatment, such as the re-establishment of fluxes which 
have been interrupted, and the regulation of the functions of the excre- 
tory organs, is to be undertaken as early as possible; for, like cerebral 
hyperaemia, the condition is nearly always one that is secondary. As an 
immediate remedy, one of Chapman's bags may be filled with ice- water . 
and applied to the back for ten or fiften minutes at a time, or the ether 
spray will answer the same purpose. 



SPINAL IRRITATION. 259 

. SPINAL IRRITATION. 

(spinal anemia ?) 

Synonyms. — Ischeraie de la moelle. Ansemie de la moelle. 

The brothers Griffin ^ were the first to describe this interesting affection, 
and since the appearance of their first paper in the London Medical and 
Physical Journal in 1829, very little has been added to our knowledge of 
this condition, which was fully considered so many years ago. The pa- 
thology of the affection was by the Griffins supposed to consist primarily 
in an irritation of the sympathetic ganglia, and they divided their cases 
into three varieties, viz., those in which the cervical, dorsal, or lumbar 
portions of the sympathetic nerves were involved. In later years other 
observers, consider the affection due to an anaemic condition of the cord, 
and go so far as to attempt to localize anaemia of the different columns, 
I am disinclined to agree with them, not only because I believe that spinal 
irritation depends sometimes upon hypenemia, but I think that this condi- 
tion is due more to a loss or abnormality of cell-functions. I am therefore 
disposed to adopt the views of the Griffins, and consider " spinal irritation" 
to be a condition due to a primary perversion of the functions of the 
sympathetic system, or to a secondary ischsemic state, and that in some 
parts of the cord both abnormalities of circulation exist. Dr. V. P. 
Gibney advanced the view before the American Neurological Association 
(session of 1877) that spinal irritation was, in the majority of cases, a 
meningeal affection, and was usually the result of injury of some kind. 
In support of this theory he brought forward a number of cases, all of 
them of great interest. I am strongly inclined to accept Dr. Gibtiey's 
explanation, but not in its entirety- Spinal irritation is very probably 
due not only to affections of the cord alone, but to the meninges as well, 
as the symptoms of spinal tenderness suggest. That a great many cases 
arise from disordered functions of other organs, there can be no doubt, and 
the history of injury is very often absent. 

Symptoms. — The indications of spinal irritation are quite varied, 
but there are several which are distinctly pathognomonic One of these 
is spinal tenderness. If the observer makes firm pressure with his thumb 
at different points over the intervertebral spaces, he may cause the patient 
to wince where a painful point receives the pressure. These tender spots 
may be either in the cervical, dorsal, or lumbar regions, but more often 
the cervical or dorsal. Sometimes the skin is so hyperaesthetic at these 
places that the pressure of the clothing is suflicient to cause the wearer 
great discomfort ; and such patients, be they women, are fidgety and irri- 
table. Pressure made at certain points may be followed by pain, not only 
in the region pressed upon, but at distant parts ; for instance, in one of 
Griffin's cases pressure made over the dorsal vertebra was followed by 

^ Observations on Functional Affections of the Spinal Cord and Ganglionic System 
of Nerves, etc., by Wm. and Daniel Griffin. London, 1843. 



260 DISEASES OF THE SPINAL CORD. 

pain in the sternum. Pain also of a darting or lancinating character fol- 
lows such pressure, and sometimes when the lumbar region is its seat there 
may be twinges which travel down the crural and sciatic nerves. So, 
too, may there be radiation of pain about the chest when the dorsal por- 
tion of the cord is subjected to this procedure. Pressure over the cervi- 
cal intervertebral spaces produces vertigo, headache, and nausea. With 
irritation of the cervical region, vertigo is quite pronounced. Memory 
is affected, and hysterical manifestations are quite common ; while in- 
somnia and headache, disordered vision and facial neuralgia, vomiting, 
and respiratory troubles are all prominent symptoms. The headache is 
connected with soreness of the scalp, and is of a neuralgic character, and 
the fifth nerve is so extensively affected that toothache, faceache, and deep 
orbital pains when they occur, a^e almost intolerable. As an evidence of 
disordered function of the fifth nerve, there may be trophic changes in the 
cornea, such as ulceration, and there is in some cases keratitis. Cervico- 
brachial neuralgia may exist in addition to the facial neuralgia, and may 
be either one-sided or bilateral, and pressure made upon the cervical ver- 
tebrae may greatly aggravate the neuralgia. Diplopia, amaurosis, and 
other visual troubles are annoying in the extreme, and the intense hyper- 
sesthetic state of the organs of special sense may give rise to hallucina- 
tions of sight or hearing. There is not rarely photophobia of a distress- 
ing character, so that the individual is obliged to stay in a darkened room. 
Deafness is an occasional symptom, and ringing in the ears is an indica- 
tion of cerebral anaemia co-existent with the spinal troubles. The gastric 
mucous membrane may be in an extremely irritable condition, so that 
the food is speedily ejected, and with the vomiting there is nausea with 
vertigo. The spinal origin of this symptom may be satisfactorily proved 
by applying a blister to the painful spot. Various respiratory and cardiac 
irregularities are quite constant accompaniments of spinal irritation. 
Among these are attacks of dyspepsia, angina, palpitation, coughing, or a 
sense of pressure and discomfort in breathing, asthma, etc. Urinary 
troubles may exist when the morbid spinal condition is situated lower 
down, and often ovarian neuralgia. Convulsive movements of the legs 
and obstinate constipation swell the list of symptoms. A form of paraple- 
gia, usually of an hysterical nature, but sometimes so constant as to seem 
to be dependent upon some organic lesion, occasionally symptomatizes the 
disease. There is even lowered temperature, though the patient may 
complain of subjective sensations of warmth; but the paraplegia is never 
attended by any evidences of the real condition which follows myelitis. 
The action of the bladder and rectum is normal, and the electro-muscular 
contractility and refiex excitability are, if anything, increased, and the 
anaesthesia or hyperaesthesia, if it^ exists, is quite unimportant. 

The following history was given to me in the patient's words, and is so 
graphic that I consider it worthy of reproduction : — 

Is^ year, 1867. There was some cerebral anaemia. Inability to think 
consecutively, or to do anything that required looking after ; constant 



SPINAL IRRITATION. 261 

nausea and dizziness ; a burning in head and spine, and an occasional 
deep seated and momentary pain in the head ; an excessive demand for 
pure air ; extreme hypersesthesia of skin ; sleeplessness ; worried feeling 
in the ovaries. 

2d year, 1868. Head symptoms slightly improved ; body grew weak 
and tremulous; felt as if starving to death, though with good appetite 
for nourishing food. Nausea not constant, but occurring every night be- 
tween nine and ten, and lasting about an hour. 

2>d year, 1869. Mind grew painfully active, it was impossible to stop 
thinking, asleep or awake ; gradual loss of use of arms and legs, with 
distressing jerkings of latter; hysterical; light and sound almost intole- 
rable. 

Ath year, 1870. Commenced walking after lying in bed seven months. 
Dizziness, sleeplessness, tremor ; burning in head and spine continued. 

bth year, 1871. Same as fourth year, with some alleviation. 

Qth year, 1872. Material changes were more sleep, arrested condition 
of brain, and tremor not constant. 

Itli year, 187-3. Dizziness, which had been constant from the beginning, 
ceased. Ability to converse, and listen to any amount of reading, attend 
lectures, etc. Pain or distressed feeling in head most of time. More de- 
pression of spirits than ever ; sleep full of nightmare. Neuralgic pain ; 
appetite indifferent ; bowels torpid ; menses irregular and overabundant, 
extremely painful, and prostrating. 

The patient was 29 3^ears old, and married. She is in appearance 
anaemic, evidently of a strumous diathesis, and somewhat hysterical. Her 
pupils are dilated, aud there is decided muscular asthenia She cannot 
read, and. when she attempts to do so, there is a peculiar dizziness, or, as 
she very pertinently calls it, a "nausea of the brain." If reading is per- 
sisted in, the dizziness is excessive, and there is ultimately vomiting. Her 
headache is vertical, and some uneasiness is produced by pressure made 
over cervical vertebrae. Her urine is copious and abundant, and. con- 
tains phosphates. CDustipation is persistent and obstiuate. At my re- 
quest Dr. Loring examined her eyes with the ophthalmoscope, and found 
atrophy of the left optic disk. 

Jan. 30, 1874. Strychnia, iron, and phosphoric acid were given, and 
absolute rest required and enjoined; and one month later she returned, 
feeling very much improved. It is possible for her to read two hours at 
a time without being fatigued, and her spirits are very much improved ; 
her depression has somewhat disappearefl, and she sleeps much better.* 
A curious feature of this woman's disease was excessive somnolency 
during the day, and it was often necessary to use violent measures to 
arouse her from her very profound sleep. Daring the evening she became 
very animated and bright, talking brilliantly upon all subjects, and it 
was not until midnight before she again felt a disposition to sleep. In 
her case evidently the menorrhagia Avas the cause of the anaemia. 

Causes. — The victims of spinal irritation are nearly always women, 
and very rarely men. It may safely be said that nine-tenths of all the 
cases are females. It rarely occurs before puberty, but after that time may 
make its appearance, and then is generally dependent upon, or associated 
with, irregular or profuse menstruation. It not rarely begins at the 
menopause, but is more often of earlier origin. Hereditary predisposition 
seems to have much to do with its development, and various mental causes 



262 DISEASES OF THE SPINAL CORD. 

play an important part in its production ; care, worry, and overwork 
being among these. Various debilitating diseases, childbirth, and bad 
habits, may be enumerated as additional causes. 

Morbid Anatomy and Pathology. — Spinal irritation being a 
functional disease, it is impossible to find a.nj post-mortem indications, 
unless they, perhaps, are foci of low inflammatory action, such as thick- 
ening of the neuroglia, or simple atrophy. 

As to its pathology, I have already expressed my views in regard to 
the probability of both hypersemic and anaemic conditions as pathological 
factors. It is impossible, I am convinced, to locate the point of irritation 
in either of the columns, and any attempt to do so is an impossible refine- 
ment of diagnosis. We may approximate its seat by the region of ten- 
derness, and the predominance of special groups of symptoms ; and this 
is all that I believe to be possible. Spinal irritation may undoubtedly 
result from — 1, reflected irritation; 2, impoverished blood-supply; 3, 
local changes dependent upon disease of adjacent tissues. 

The labors of Brown-Sequard, Bernard, and lately Lauder Brunton, 
have showed satisfactorily the intimate relation between the sympa- 
thetic and cerebro-spinal systems ; and the o bservations of the former 
are especially valuable because of their pathological bearing. Not only 
may distant organs send irritating impressions to the cord, to be followed 
by vaso-motor stimulation, contraction, and subsequent relaxation o f the 
vessels, but the intra-spinal circulation of impure blood may produce 
local irritation, imperfect nutrition of the nerve-cells, shrinkage of the 
nervous tissue, and oedema of the perivascular spaces. The chain of in- 
hibitory ganglia, described in such a beautiful manner by Brunton, 
places in close relation the different parts of the cerebro-spinal axis, so 
that there is nearly always a disturbance of several organs when the 
harmony is affected. 

The vascular cramp of Nothnagel will account for various ischsemic 
conditions in certain parts, while circulation in neighboring districts may 
be perfectly normal. Bidder^ has also shown that complete alteration of 
vascular calibre is impossible, so that at best there is contraction but at a 
certain point, while the other part of the vessel may be dilated. 

Bidder's experiments also demonstrated that excitement or exaggerati on 
of function may exist with depressed function at the same time, in a 
compound organ. 

It is therefore reasonable enough to consider that spinal irritation is 
not altogether dependent upon spinal anaemia. 

The production of special symptoms is explained by the involvement 
of sympathetic, cranial, or spinal nerve-roots. The headache may result 
from cerebral ansemia, as may also the mental and hysterical symptoms ; 
while the visceral disturbances arise from sympathetic derangement of 
the abdominal organs. The pain resulting from pressure is due to im- 

^ Die Eeflexe sines der sensiblen Nerven du Herzen auf die motorische du Blutge- 
fiisse. 



SPINAL IRRITATION. 263 

pressions conducted to the over -sensitive centre by the cutaneous nerves. 
It is almost unnecessary to allude to the production of spasms, reflected 
pain, and the numerous dyssesthesia. 

Diagnosis. — Spinal congestion, spinal meningitis, and incipient in- 
flammation of the cord may suggest themselves to the observer. As to 
the first, difierential diagnosis is often imj)ossible, unless there be actual 
paresis. The absence of great spinal tenderness is also an element in di- 
agnosis. Spinal meningitis is connected with tenderness, but it is not 
aggravated so much by pressure as by muscular movements. There are 
also present muscular spasms of a painful character. 

Myelitis in the beginning is attended by waist constriction, which is too 
marked to be mistaken ; and besides paralysis of motion and sensation, 
there is atrophy, as well as progressive symptoms. The presence of gas- 
tric disorders, which are so marked in nearly all cases of spinal irrita- 
tion ; of headache, and great languor, a generally depraved physical 
state, and the existence of uterine trouble, should all be taken into 
account. 

Griffin alluded to several other disorders likely to produce some of the 
symptoms of spinal irritation. These are rheumatism, which is sometimes 
causative of spinal soreness, and various acute diseases, which, however, 
present so many symptoms of a distinct character as to do away with any 
chance for mistake in diagnosis. The pain of rheumatism is generally 
so severe and absorbing that the patient's mind is constantly directed to 
it, while affections of the joint usually coexist. 

Prognosis and Treatment. — If the patient be promptly taken in 
hand it is often possible to cure the disease, but I am inclined to consider 
well-established spinal irritation the most discouraging and intractable 
functional neurosis that is to be met with. Commonly connected with 
ovarian or uterine derangement, it defies the best-directed efforts of the 
physician ; and, if the factor cannot be removed, the patient becomes a 
confirmed invalid. It is, therefore, proper in all cases to search for the 
cause, and in three-quarters of the female cases it will be found in the pel- 
vis. If there be general ansemia, or some other depraved condition of the 
system, we are to "build up" our patient with cod-liver oil and tonics, 
and a very excellent one is the following : — 

R. Ferri et ammon citratis, 5iij« ; 

Tr. gentianse, §iv. — M. 

Sig. — A teaspoonful in water after eating. 

Phosphorus, either in the form of Thompson's solution, or the phos- 
phuretted oil, quinine, pyrophosphate of iron, Horsford's acid phosphates, 
the syrup of the combined phosphates, are all in order. Nutritious food 
and extract of malt are to be given, and a liberal use of stimulants is 
strongly recommended. Strychnine sometimes does good, and at others 
a great deal of harm ; and in cases where there is very severe pain, I pre- 
fer other remedies. 



264 DISEASES OF THE SPINAL CORD. 

Opium in small closes is often of great value, and its effects are imme- 
diate and excellent. External counter-irritation, either by the actual 
cautery applied on the painful points, a blister, or some irritating oint- 
ment, is advised, and if vomiting be present, a blister on the epigastrium, 
subsequently dusted with morphia, allays the irritability of the stomach. 
I have used with success, and would recommend, galvanism (the descend- 
ing current), the positive pole being placed upon the nucha, and the ne- 
gative in the groin. Applications lasting five or ten minutes every day, 
or every other day, are sufficient. 

Galvanization of the cervical sympathetic is an important form of aux- 
iliary treatment. Heat and cold alternately applied to the spine are fol- 
lowed by excellent results ; or Chapman's ice-bags, filled with hot water, 
and placed in contact with the spine for fifteen or twenty minutes daily, 
are beneficial. 

Open-air exercise, Turkish baths, and massage, all help the patient ; 
and Mitchell's rest-treatment, already described, is one of our best modes 
of treatment in confirmed cases. 



MYELITIS. 265 



CHAPTER IX. ^ 

DISEASES OF THE SPIIs^AL CORD (Continued) 

INFLAMMATION OF THE SPINAL COED— MYELITIS. 

Synonyms. — Myelitis. My elite aigue, chronique. Riickenmarkeiit- 
ziindung. 

Definition. — Inflammation of the spinal cord, usually attended by 
paralysis of motion and sensation below the seat of the spinal lesion, l)y 
involuntary stools and incontinence of urine, and by absence of reflex ex- 
citability and electric contractility in the paralyzed parts, and a tendency 
to extension upwards, results in death in a very short time from paralysis 
of the intercostal muscles, especially should the pathological condition be 
an acute one. Inflammation of the spinal cord may extend across the 
cord, when it is called transverse myelitis; or longitudinally, when the 
terms ascending or descending are applied. The features of an attack of 
transverse myelitis, which, as an acute condition, is so rapid in develop- 
ment that it suspends the functions to a great extent of the columns of the 
cord, so that we get a simultaneous or rapid impairment of the conductors 
of motion and sensation, and the disordered functions of organs inner- 
vated by nerves coming from the cord below the level of the diseased por- 
tion; or, on the other hand, the integrity of the different conductors of 
the cord may be gradually impaired, so that many months or years may 
elapse before the morbid process extends across a plane, destroying suc- 
cessive parts. In the other forms in which the inflammatory process tra- 
vels upwards or downwards, the loss of function is more irregular. Still 
another form exists, in which the periphery is affected, with or without 
meningeal complication. 

ACUTE myelitis. 

Symptoms. — The disease begins rather suddenly, generally with pain 
in the back, which is aggravated by pressure, and an uneasy sense of 
tightness about the body. These unpleasant sensations may be preceded 
by formication and tingling of the feet, some loss of power, and the de- 
velopment of more or less fever, during which the temperature may be 
very much elevated. This is especially the case when the upper part of 
the cord is involved. These symptoms are followed in several hours, or 
after a day or two, by loss of power in the lower limbs and by an aggra- 
vation of the spinal pain. The patient will find it impossible to pass his 
urine, and if he is not relieved by a catheter will suffer great distress ; or 



266 DISEASES OF THE SPINAL CORD. 

there may be final relaxation of the sphincter, and it may flow from him 
Avithout his knowledge. These symptoms are sometimes presented before 
a physician is called in, and at his visit there may be complete paralysis 
of the lower extremities. The surface of the limbs is cold and utterly de- 
void of sensation, and the soles may be tickled or the muscles pinched 
"without any attempt being made upon the part of the patient to withdraw 
his feet. This reflex excitability, however, is not always lost in the be- 
ginning, but may be present when the onset of the disease is gradual, and 
the patient is entirely unconscious of the occurrence of these movements. 
If a heated substance be applied to the back, it will be found that its 
presence will not be appreciated below the point of spinal inflammation, 
but when it is passed over the diseased tract the pain is greatly increased. 
Above this level, normal sensibility exists, and the degree of heat is 
readily perceived. The attention of the physician is attracted by the am- 
moniacal odor of the urine, which, as has been stated, may flow from the 
patient without his knowledge, and the contents of his rectum may pass 
away in the same manner. Hyper^esthesia is an exceptional late feature, 
but it may form one of the initial symptoms in conjunction with trembling 
of the limbs. After the paralysis takes place, the temperature is lowered 
several degrees, and circulation is very defective. At the end of a week 
there may be indications of the upward extension of the spinal inflamma- 
tion if it be progressive, and it is sometimes recognized by the tendency 
to priapism and the distress in breathing, and with these there may be 
hiccough and hurried respiration, the number perhaps reaching 48 in 
the minute. Bedsores form over the sacrum, and there is every appear- 
ance of approaching dissolution. The skin becomes clammy, and there 
may be rigors ; while the pulse grows small, fluttering, and the voice very 
weak, and ultimately the patient dies, his mind remaining clear to the 
end. If, however, the structural alteration progresses upward, it is very 
probable that the mode of death will be asphyxia. As exceptional in- 
stances, cases have been recorded in which there was myelitis of the upper 
part of the cord, with complete paralysis of the upper extremities, while 
the lower limbs, the bladder, and rectum were not aflected, and other 
equally rare forms are occasionally noted. When the dorsal portion of 
the cord is the seat of inflammatory action, the respiratory symptoms are 
immediate, and the breathing becomes embarrassed at once. The pneu- 
monia occurring so often in a late symptom of myelitis is undoubtedly of 
nervous origin, and commonly indicates the implication of the medulla.. 
The pneumonia is complicated by some bronchial trouble. Vulpian^ and 
Arnozan^ lately have given consideration to the connection between spinal 
and pulmonary diseases, under certain circumstances, and the former is 
of the opinion that the sympathetic roots of the intercostal nerves are in- 
volved. 

The prominent symptoms of this interesting disease may be summed 
lip as- — 

1 Maladies de la Moelle, p. 185. ^Des lesions trophiques, etc., p. 198. Paris, 1880. 



MYELITIS- 267 

1. Paraplegia of sudden or gradual origin, attended by anaesthesia and 
analgesia, but usually preceded by dysjesthesia of various kinds, or actual 
hypersestbesia. It may be accompanied in the beginning, according to 
Radcliffe,^ who has observed this symptom in severe cases, by " uncontrol- 
lable restlessness." Paraplegia is nearly always the form of lost power, 
though in rare cases there is hemiplegia. There may be, in exceptional 
cases, variations in sensibility, the symptoms of anaesthesia being absent 
when the anterior columns are alone partially affected. Again, in other 
cases one leg may be paretic and the other anaesthetic. The onset of 
the paraplegia may be very sudden, and the disease prove rapidly fatal. 
Jaccoud^ has seen one case in which the paraplegia developed in thirty-six 
hours from the commencement of the disease. Eighteen hours afterwards, 
the autopsy revealed a purulent meningo-myelitis of the entire lumbar 
and part of the dorsal segments of the cord. The extent of the paraplegia 
is of course governed by the seat and course of the myelitis. If the lum- 
bar portion of the cord be destroyed, the lower extremities, and the mus- 
cles of the abdomen and sphincters will be paralyzed ; if the myelitis 
extends so that the dorsal portion and the eilio-spinal centre are involved, 
the arms are paralyzed, and pupillary changes with irregularity of cardiac 
functions are produced. When the lesion is still higher, and the cervical 
portion of the cord is involved, there may be, in addition to all these 
forms of paralysis, various difficulties in swallowing, speech, and respira- 
tion, and the patient dies from asphyxia. 

2. Reflex excitability is generally abolished entirely, or impaired to a 
great extent. Occasional exaggeration is seen in the earliest stages, or 
when the myelitis involves limited regions, especially the lumbar segment. 
Jaccoud says : " Durant la periode d'exageration (hyperkiuesie reflexe) 
le segment lombaire soustrait a I'influence du cerveau manifestait son 
action proper avec la puissance accre qu'elle tirait de son isolement ; du- 
rant la periode d'abolition (akindsie reflexe) cette action propre ou spinale 
est an(^antie parceque les elements qui en sont dou^s sont detruits." 

3. Electric contractility and sensibility are abolished or greatly lowered. 
The only exception to this rule is when the reflex excitability is in- 
creased. 

4. Muscular atrophy as a result of severance of spinal innervation 
sometimes follows. This may take place in from four to six weeks. The 
atrophy is general, and is of course attended by absence of electro-mus- 
cular contractility and by coldness of the surface. 

5. Bedsores and other evidences of defective cutaneous innervation are 
present. The skin becomes swollen, or there may be at first great dry- 
ness and redness, or oedema at the points subjected to pressure. A hard, 
red bullous nodule may form, and subsequently break down, and some- 
times large patches of tissue are rapidly destroyed. According to Ash- 

1 Op. cit., p. 314. 2 Path. Interne, vol. i. p. 315. 



268 DISEASES OF THE SPINAL COKD. 

urst bedsores are more frequent when the lesions of the cord are low 
down. 

In hemiparaplegia when the lesion is unilateral the bedsore is also uni- 
lateral and upon the side opposite the lesion, and bearing in mind the 
law of Brown-Sequard, loss of power and vaso-motor paresis with hyper- 
sesthesia upon the side of the lesion and anaesthesia on the opposite side, 
the bedsore appears on the anaesthetic side. 

Arnozan reports a case in which a monoplegia affecting one limb was 
followed by bedsores upon both buttocks, that upon the paralyzed side 
being one and a half centimetre in its largest diameter, while that upon 
the other was the size of a silver dollar. The paralysis was at first 
supposed to be cerebral in origin, but the occurrence of violent lum- 
bar pain and atrophy supported its spinal character. Cases are on record 
where a brisk arthritis developed upon the sound extremity, while upon 
the other a bedsore appeared. 

Brown-Sequard according to Arnozan believes that the occurrence of 
bedsores is most frequent in cases where there is incontinence of urine. 

6. The sphincters are paralyzed, the urine is intensely alkaline, the walls 
of the bladder being paralyzed, and as a consequence a certain amount 
of urine remains in that organ in a decomposed state, and rapidly induces 
an alkaline reaction in that which may collect in addition before it is 
discharged. Brown-Sequard is inclined to consider that this condition 
of affairs is pathognomonic of disease of the dorsal region, and I infer 
holds that it is essentially a nervous symptom. Leroy d'Etiolles^ has 
alluded to cases of paraplegia, the so-called paraplegie urinaires which 
folloiv bladder troubles in which cystitis with purulent and decomposed 
urine, and perhaps ulcerated thickening and local paralysis of the vesical 
walls are found. Frequent catheterization or sounding aggravates the 
trouble, and a myelitis may result either as a reflex nervous trouble, or 
as a result of absorption. Radcliffe alludes to a reflex spasm of the 
sphincter ani which occasionally occurs in this disease, but this symptom 
is so exceptional as to need but passing comment. The paralysis of this 
muscle is ordinarily so complete as to be followed by the almost constant 
escape of softened feces and watery discharges. The sphincter ani some- 
times however shows an abnormal amount of reflex excitement. A 
favorite subject with those who endeavor in courts of law to prove spinal 
disease and obtain heavy damages, is the possible atrophy of the male 
parts of generation. Such a consequence of myelitis is exceedingly rare, 
though Curling has admitted that wasting of the testicles may follow. 
Arnozan quotes Klebs, who says that often when wounds of the lumbar 
cord are near the genito-spinal region, or in connection with certain 
paraplegias the spermatozoa disappear and there is cellular degeneration. 

7. Increase of temperature and pulse call for no special mention. Oc- 
curing with paralysis of the lo wer extremities and no loss of conscious- 
ness they can symptomatize but two acute spinal affections, myelitis and 

^ Des Paraplegies, 1856. 



MYELITIS. 269 

meningitis. The spasmodic movements of the latter disease, however, 
are not observed in myelitis, so that it possesses at least some diagnostic 
importance. The temperature varies from the normal standard to 10-4° 
or 105°, and the pulse may reach 160. 

8. The constricting hand sensation or parsestliesia, which is more marked 
in myelitis than any other form of spinal disease, is generally likened by 
the patient to that which might result if a tight cord were tied about the 
body. It is usually located at the waist, and sometimes when it is not 
complained of may be developed by a sharp blow on the back, or by the 
application of an electrode to the spine. 

CHRONIC MYELITIS. 

Symptoms. — The disease sometimes takes a more slow course. The 
paralytic symptoms are much less sudden in their onset, and occur one 
after another, so that the extension of the inflammation may be sometimes 
traced. For some time, perhaps for several months, there may be dis- 
orders of sensation, such as tingling spinal pain, and the " constricting 
band." The perception of pain in the affected limbs, though not entirely 
abolished, is greatly impaired. 

Charcot,^ Romberg,^ and Cruveilhier^ have called attention to the 
curious mistakes sometimes made by patients in locating painful sensa- 
tions. Pain following the pinching of one leg is referred to the other, 
and the painful impression may take several seconds to reach the senso- 
rium. In one of Romberg's patients pressure upon the toe was referred 
to the hip. Cruveilhier's experiments demonstrated that an interval of 
from fifteen to thirty seconds elapsed sometimes before any sensation was 
excited, and that the impression had to be made several times before it 
was perceived. Electric contractility is perhaps increased, and reflex 
excitability is very much exaggerated, and may be followed by very 
violent movements. Thus, when a warm bottle is sometimes applied to 
the feet, though the temperature is not so high as to cause discomfort to 
a healthy person who touches it, the patient's legs will be violently drawn 
up ; this always suggests a meningeal complication. Dyssesthesise are re- 
ferred to, and pains in the joints and bones, especially aggravated by 
humidity of the atmosphere, are spoken of by the patient. The paralysis 
of motion is much less extensive than it is in the acute form and in the 
beginning ; and spasms of the muscles of the lower extremity are quite 
violent. Subsequently, however, they disappear as the loss of power be- 
comes more complete, and at this time there are lowered temperature and 
electric irritability instead of the primary exaggerated condition. The 
bladder and rectum are subsequently affected, and various degrees of de- 
ranged function may be noticed. Olc of my patients is obliged to pass 



1 Op. cit. 

'^ Manual of the Nervous Diseases of Man, Syd. Trans., vol. i. p. 267, etseq. 

^ Anatomie Pathologique, livre xxxviii. p. 9. 



270 DISEASES OF THE SPINAL CORD. 

his water every ten or fifteen minutes, and his bowels are so constipated 
as to require an injection every day. The individual generally loses his 
desire for sexual gratification if the disease is at all advanced, though in 
the beginning there may be a marked disposition to erection. Muscular 
atrophy takes place if the anterior horns be affected. 

An increase in the tendinous reflex is shown very markedly, especially 
if the gray matter of the cord be affected. The dorsal clonus is quite 
violent and the slightest tap upon any of the muscles causes a series of 
convulsive movements of great violence. The jarring of the patient will 
even give rise in some instances to an irregular coarse tremor of the 
lower extremities, which may last for several seconds. The invasion of 
the lateral columns is symptomatized by contractures, great spastic rigidity 
and discomfort. The legs and thighs may be so drawn up that the heels 
may make painful pressure upon the buttocks, and the contact of the 
knees when the adductors are the seat of contracture give rise to skin 
changes, and even ulcers. I have repeatedly found a "glazed" boggy 
skin readily pitting upon pressure, though the skin is usually of a muddy 
white color and either clammy or even dry and scurfy. Ferrier discov- 
ered a peculiarity in this disease due to skin changes ; that if a silver 
coin was rubbed upon its edge a dark line would remain for some time. 

Causes. — The common causes of myelitis are injury, syphilis, acute 
diseases, exposure, and extension of meniugeal disease. Falls and blows 
upon the back are the origin of the majority of cases, but I consider 
syphilis to have a very great deal to do with even these, when .often it is 
not suspected. Meningeal thickening or acute meningitis undoubtedly 
play an important part as mechanical factors ; and in many cases re- 
ported, disease of the vertebrae has been found to produce the myelitis. 
Potts' disease seems to be a fruitful cause of myelitis and usually of a 
very serious variety. When so produced the atrophy and contractures 
of the limbs and active motor phenomena point to a decided implication 
of the antero-lateral columns of the cord. In such cases it is rare for the 
meninges to escape inflammatory action, and as a consequence, the symp- 
toms of meningitis are added to those of the myelitis. 

The existence of a large aneurism of the aorta, may also by erosion, 
prove to be a source of injury to the cord, and in some cases it is neces- 
sary to use great caution in making a diagnosis. In a case recently under 
observation, the gradual development of an irregular paraplegia was ac- 
cidentally found to be associated with the presence of an abdominal 
aortic aneurism of large size, which produced a great deal of pain. There 
is a variety of myelitis which deserves the most careful study, because of 
its medico-legal importance, and I allude to that following spinal concus- 
sion. Cases of " railway spine " are so common in these days of railroad 
accidents, and there is so much danger of malingering, that I must add a 
word of advice to those who have occasion to go into courts of law as ex- 
perts. That iDflammation of the cord may follow a concussion, I think 
there can be no manner of doubt, and some of the cases of Erichsen sup- 
port this theory ; there are many others, however, in which hysteria plays 



MYELITIS. 271 

SO important a part as to lead the examiner astray, unless lie is prepared to 
avoid the error of accepting the patient's recital of subjective symptoms 
as conclusive. I do not think that any jury should give damage unless 
some physical signs of actual spinal disease are present. 

The production of spinal inflammation from injury which does not pro- 
duce external wounds, need not be of immediate appearance. It may be 
masked at first, but with due care it should be detected much earlier than 
Erichsen is disposed to grant. When present, the symptoms are con- 
spicuous because of their irregularity and behaviour. Of the persons 
applying to the courts for redress, there are few who have suffered from 
early acute symptoms, but the cases are peculiar and therefore difficult 
to examine. In many of them unequal atrophy of the limbs, increased 
tendinous reflex activity, and ocular changes are present, while all are 
likely to complain of dysDesthesia, loss of memory and mental feebleness, 
and incapacity for work. In those who sham, it will be found that there 
is an utter absence of physical changes, the tendinous reflex is neither 
exaggerated nor absent, the muscles respond well to electric stimulation, 
and the story of aches and pains is out of proportion with any possible 
kind of spinal trouble. The loss of memory and enfeeblement for brain 
work rarely stand the test of critical examination, and the patient's an- 
tecedent history does not bear out his story. 

Venereal excesses, onanism, and continued dissipation are direct causes 
which should not be overlooked. 

Morbid Anatomy and Pathology .^-When the vertebral canal 
is opened, the investing membranes slit up, and the cord exposed, it will 
be found to be greatly changed in color and consistency at certain parts, 
and it may be diffluent and of a pinkish color. Scattered throughout the 
softened portion collections of blood may sometimes be found, and these 
are more often in the greatly altered gray substance, from which the dis- 
ease seems to have started. At other points there maybe discovered evi- 
dences of slight vascular changes, such as occur in the red stage of cerebral 
softening. There may be adhesions of the meninges to the cortex or col- 
lections of pus between them. In the more slow form of degeneration 
(chronic myelitis) the process may not be so widespread, limited areas 
being only affected. As the result of either form there may be an atrophic 
condition of the cord, or an actual hardness which we shall presently speak 
of in our consideration of sclerosis. The microscopical appearances are 
the following : the vessels are enlarged, varicose, or broken, and are sur- 
rounded by effused haematine ; the nerve-tubes are swollen, irregular, and 
disrupted, and the axis cylinders substituted by oil-globules or granular 
debris ; and the nerve-cells may have been broken down and become 
simple granular masses of a round or ovoid shape (Gluge's corpuscles). 
Fat globules may be found scattered here and there if the cord of an ad- 
vanced case is examined ; and the connective tissue may be found to be 
thickened and increased in density. Pus-corpuscles may also be seen. Dr. 
R. T. Edes, who, with Dr. S. G. Webber, of Boston, have done so much 
pathological work in the field of myelitis, presented a case to the American 
Neurological Association, which presented a not uncommon microscopical 



272 DISEASES OF THE SPINAL CORD. 

appearance. The myelitis had lasted four months, and while the white 
matter was unaffected Edes found the gray nervous substance to contain 
little vacuoles in the anterior horns. The ganglia cell processes were 
shrunken and broken. Putnam, of Boston, had seen a case presenting 
the same appearance, and in his observations, there were collections of 
fat in the ganglion cells, and he was disposed to regard this deposit as in- 
dication of an earlier stage of the same process, which ended in Edes' 
case by the formation of vacuoles. In fact, he found openings at a lower 
level. 

Jaccoud^ speaks of two kinds of myelitis — my elite en foyer and myelite 
central. In the first form the meninges will be found to be injected and 
adherent to the nervous substance, and the nodules or patches may be 
several centimetres in length or smaller. These foyers are quite distinctly 
separated from each other by healthy tissue, and when one is removed 
the nidus in which it has formed is seen to be in quite normal condition. 
The anterior columns and anterior nerve-roots are often found to be in- 
volved ; and the latter are the seat of " petites nodosites exuberantes." 
When the disease assumes a chronic form, these softened patches may 
become encysted as in cerebral softening. The central form, as its name 
implies, begins in the gray matter, and generally extends longitudinally. 

^Dr. Gowers gives a most comprehensive diagram for the localization 
of spinal disease which I have reproduced (Fig. 37). It is founded upon 
anatomical and pathological data, and will enable the student to fix the 
level of the lesion by a consideration of the anatomical significance of the 
symptom. 

Diagnosis. — It is necessary to exclude spinal meningitis, locomotor 
ataxia, spinal tumors, and spinal congestion. 

Spinal Meningitis. — What I have already said in a previous article 
renders further consideration unnecessary. 

Locomotor Ataxia. — There is no paralysis of motion in this disease, 
but rather an increased muscular activity, which is expressed by the vio- 
lent manner in which the patient throws out his foot ; while in chronic 
myelitis he drags one foot after another. The neuralgic pains in the ex- 
tremities are absent in myelitis ; while in locomotor ataxia they are mark- 
ed symptoms. In myelitis there are none of the paralyses of cranial 
nerves so commonly found with sclerosis of the posterior columns ; the 
tendon-reflex is, moreover, usually absent in locomotor ataxia. 

Spinal Tumors. — The presence of a spinal tumor may sometimes pro- 
duce pressure upon the cord, and give rise to some of the symptoms. The 
slow development of the growth is, however, attended by corresponding 
slowly appearing symptoms, and the paralysis is not complete. The 
chance for doubt as to the condition arises when secondary myelitis results 
from such a tumor. 



^ Path. Interne, ed. 2me, vol. i. p. 310. 

2 The Diagnosis of Disease of the Spinal Cord, W. K. Gowers, M.D., F.R.C.P., 
London, 1880, p. 52. 



MYELITIS. 
Fig. 37. 
MOTOR. 



273 




p St.-mastoid 
" Trapezius 



Diaphragm 

vSerratus 
j Shoulder 1 



Hand 

(ulnar lowest) 



SENSORY. 



I Neck and Scalp 
J Neck and Shoulder 



Shoulder 
I Arm 
Hand 



Intercostal 
Muscles 



Abdominal 
Muscles 



REFLEX. 



Flexors, hip 

Extensors, knee 
y Adductors"] 



!-hip 



Abductors 



Extensors(?) ^ 
Flexors, kne'e (?) 

Muscles of leg 
moving foot 



Perineal and Anal 
j muscles 



Front of Thorax 
Ensiform area 



Abdomen 
(Umbilicus loth) 



I Buttock, upper 
r part 

Groin and scrotum 
(front) 

f outer side 

Thigh \ front 



1 t inner side 

Leg, inner side 
'Buttock, lower 
part 

Back of Thigh 

ani I . except 

LFootj ^^^^^Pa^* 

' Perineum and 
Anus 



Skin from coccyx 
to anus 



Scapular 



" Epigastric 



Abdominal 



y Cremasteric 

1 

-' '► Knee reflex 



Gluteal 



Ankle clonv^ 
Plantar 



Fig. 37.— Diageam and Table showing the Approximate Relation to the Spinal Coeds of the 
Vaetotjs Motor, Sensory, and Reflex Functions of the Spinal Coed. {From anatomical and 
pathological data.) (Gowers.) 

18 



274 DISEASES OF THE SPINAL CORD. 

Spinal Congestion^ — These serious symptoms of myelitis are never pro- 
duced by anything but a degenerative process, and there are rarely bed- 
sores, alkaline urine, or the profound disturbances of sensation or motion 
which characterize myelitis. 

Prognosis. — In every case much depends upon the nature of the 
cause, and the extent of the cord involved. If there be a traumatism, of 
course this gives the disease a serious character, and death may occur in 
a few days. 

Acute myelitis may run an exceedingly rapid course carrying off the 
patient in two or three weeks, and in such cases there are usually febrile 
symptoms. Webber^ says, " It is not always easy to decide whether a 
case of myelitis should be called acute or chronic. The integrity of the 
whole cord is so essential to its proper function that if only a small por- 
tion is affected there are irregular and defective actions in all that part 
below, and perhaps in parts above. If an acute affection of one segment 
is recovered from with permanent injury of the diseased portion, the result- 
ing symptoms are permanent, and there is chronic derangement of function. 
Inflammation may begin in an acute form in the lumbar enlargement, 
and then advance upwards slowly, yet pathologically, with the same 
characters in each segment of the cord ; as no vital parts are affected, 
life is prolonged, and the cases seem to be chronic in time, while being 
acute pathologically. In fatal cases, then, the chronicity or acuteness 
depends upon whether vital centres are attacked early or late in the dis- 
ease." 

If the myelitis result from pressure from diseased and displaced verte- 
brae, the result, though more distant, is equally bad. Very few cases re- 
cover entirely from chronic myelitis, and in those that do, the lesion must 
either be due to syphilis, or be very limited 

The reparative action of a bed-sore is a valuable index of the central 
lesion. I have repeatedly witnessed the most varying and rapid changes, 
either on the result of an improvement, or the reverse in the diseased 
cord. 

Treatment. — Counter-irritation, cold, and ergot are useful in the 
early stages of the acute disease. The former may be produced by the 
actual cautery, but care should be taken not to burn extensively, as the 
tissues are too ready to slough. Ice-bags may be used, and the patient 
should be laid on a water-bed, and kept as clean as possible ; the thighs 
and nates being washed occasionally with salt and water, or with hot and 
cold water alternately. The iodide of potassium, with belladonna, should 
be given internally. Should the case be one of slow development, I pre- 
fer the use of ergot in half-drachm doses thrice daily ; or we may use the 
bromides. 

The sesqui-chloride of iron seems to have enjoyed deserved popularity 
in England, and it is preferred by Kadcliffe to the iodide of potassium. 
In one case I obtained very excellent results with the tincture of the 

^ Boston Medical and Surgical Journal, vol. cii., No. 7. 



ACUTE ASCENDING PARALYSIS. . 275 

chloride of iron. Phosphorus and cod-liver oil, those valuable builders 
of nervous tissue, may be employed here with every hope that they will 
do good. In chronic myelitis they are especially serviceable, and small 
and frequent doses of strychnine are, in addition, useful. The use of the 
phosphate of silver has been so often followed by good results in recent 
cases, that I believe it should be tried, not only in this, but in other 
organic diseases. It seems to have a noticeably good influence upon the 
bladder, and in several cases I have found the patient was able to hold 
his water after its use. 

There are forms of auxiliary treatment which not only increase the 
comfort of the patient, but go far towards ameliorating his disease. One 
of these is the assumption, if possible, of a position which shall favor 
the determination of the blood from the spine. Brown-Sequard has re- 
commended that the patient should lie upon his side or belly, with his 
legs somewhat lower than the rest of the body. I have found that wash- 
ing out the bladder with a dilute solution of carbolic or nitric acid, or 
chlorate of potash, prevents the disposition to cystitis which there very 
often is in myelitis. Warmth of the limbs, established by wrapping them 
in cotton batting, with a covering of oil-silk, or the new India-rubber 
tissue-paper, opposes contractions, and stimulates the cutaneous circula- 
tion ; while application of the faradic current, and the employment of 
massage, help the patient to a great extent. The electric brush should be 
used faithfully every day, and it is better that the physician should make 
his own electrical application, than trust it toa nurse or attendant. The 
descending galvanic current of moderate strength may also be used daily. 

ACUTE ASCENDING PAKALYSIS. 

Synonyms. — Landry's Paralysis. Disseminated Neuritis (Gros). 
Progressive Paralysis (Graves). Paralysis ascendante aigue (Dejer- 
ine). 

Definition and Symptoms. — A form of advancing paralysis de- 
pending upon a rapidly developing central disease which aflTects succes- 
sive portions of the cord in its upward course until it reaches the medulla, 
when death occurs. From the absence of any distinct anatomical change 
it cannot be said to be a myelitis. Westphall could not find any changes 
whatever in cases observed by him,^ and Erb quotes various authors 
whose investigations have had the same result. 

The disease begins by vague sensory changes referred to the extremi- 
ties. There is an ansesthesia of the finger tips, so that the individual 
does not readily feel small things, and finds some difficulty in buttoning 
his clothes. He is indisposed to walk and grows easily tired, and this 
weakness in from one to six weeks increases to actual paresis, so that he 
becomes paraplegic and cannot walk at all. The disease seems to be 
confined almost exclusively to the motor tracts of the cord, and as 
the disease reaches a higher level we find a gradual loss of power in 

^ Abstract by Dr. J. J. Putnam in Boston Medical and Surgical Journal, Sept. 4, 
1879, from original " Contribution a I'Histoire des Nevrites, Paris, 1879.'' 



276 DISEASES OF THE SPINAL CORD. 

the parts above. The muscles of the abdomen become weakened, and 
the functions of the bladder and bowels are much hindered, a resulting 
atony taking place. The patient, through weakness of the muscles of 
the trunk, is unable to hold himself upright (Erb), and as the intercos- 
tal muscles become affected we find various respiratory troubles, such as 
shallowness of breathing and dyspnoea. The arms in turn are paralyzed, 
and the muscles of the neck involved, and when the medulla becomes 
affected the symptoms of bulbar paralysis are presented, and the patient 
ultimately dies of asphyxia. Sensory troubles are very light, and occur 
only when the motor symptoms are well marked. 

As negative symptoms may be mentioned — 1. Absence of atrophy, 
except the slight amount resulting from inaction. 2. No abnormal in- 
crease of reflex excitability either cutaneous or tendinous. 3. No im- 
paired susceptibility of the muscles to electric stimulation. 4. No con- 
tractions are ever present. Gros alludes to the varieties of the disease 
with reference to the duration and severity. 

" There are three varieties : (1) the acute, usually fatal in the course 
of three weeks, often before the muscular atrophy commonly met with 
has had time (it is inferred) to develop itself; (2) the subacute, ending 
either in partial recovery or in death in the course of six months to a 
year, and liable, in the former event, to relapse ; (3) the chronic, the 
most common form, lasting many years, but liable, also, to burst out into 
the acute variety at any time. The onset of the disease is commonly 
rapid, and not infrequently marked by a short febrile attack." ^ 

Gros considers the disease a centripetal affection, and calls attention to 
the tenderness at the peripheral ends of the nerves. 

Causes. — The causation of the disease is not known, and all kinds 
of theories have been advanced — cold, intoxication, the poison of 
typhoid, diphtheria and small-pox have been alluded to as elements in its 
production, and syphilis has been suggested as a factor. The history of 
metallic poisoning would suggest the possibility that in some cases it 
might play an important part in the genesis of the disease. I know of one 
patient who died from acute ascending paralysis as a result of lead poisoning, 
and it is very probable that certain forms of acute paralysis following in 
the wake of the exanthematous fevers might reasonably be supposed to 
produce a peripheral neuritis. 

Pathology. — The cord, brain and medulla have been repeatedly 
examined but without success, so far as the discovery of lesions were con- 
cerned. The sympathetic nervous system is probably primarily affected, 
judging from what Gros has said, and like some other form of spinal 
disease, in which primary changes appear in isolated groups of muscles, 
and which are supposed by modern investigators to be due to terminal 
lesions, so may this affection have a peripheral origin. Dr. Grainger 
Stewart^ in an admirable paper upon a rare form of ascending neuritis, 
which, in many respects, resembles the disease under consideration, only 

^ Edinburgh Medical Journal, April, 1881, p. 878. 



ANTERO-SPINAL PARALYSIS OF INFANTS. 277 

in the trouble he describes there is an affection of sensory nerve fibres, 
as well as motor, and there are nerve changes. From the general char- 
acter of the trouble he is inclined to believe the origin and pathology of 
the two diseases to be alike. This would point to the peripheral origin 
of acute ascending paralysis. 

Diagnosis. — It is necessary to distinguish this disease from a myelitis 
which, if transverse, is symptomatized by decided affection of motion and 
sensation, and is attended by atrophy and decided disturbances of the 
pelvic organs, such as incontinence. Adult spinal paralysis is much more 
apt to be mistaken for the disease under consideration, than anything 
else, but here there is atrophy which is so decided and irregular as to be 
unlike the slight wasting of acute ascending paralysis. Gros speaks of 
the difficulty of distinguishing the disease from simple spinal menin- 
gitis, which even after all, may be connected with the affection under con- 
sideration. So far as my own experience goes there is enough muscular 
rigidity and spastic trouble to make a diagnosis, at least in the commence- 
ment. 

Prognosis. — The duration of the disease may be very short ; even 
three or four days may be sufficient for it to run its fatal course. Wilks^ 
says, " In seeing such cases I am reminded of a spark alighting on a piece 
of touch paper, and the fire running through its length until the whole 
is quickly consumed." 

Erb speaks more hopefully, and refers to Landry, who cured eight out 
of ten cases. In some cases the disease may come to a stand still for 
a time, and have a fresh outbreak, which carries off the patient. It is pro- 
bable that the morbid process, whatever it is, may be of an exceedingly 
light grade, and affect the cord to a limited degree. 

Treatment. — Active counter-irritation seems to have been most suc- 
cessful. This may be produced by the actual cautery or the application 
of croton oil. Cupping, faradization by the wire brush, and cold douches, 
certainly have done good in the German cases. Of course the use of 
remedies and food calculated to build up the nervous system, are to be 
employed, and among these are phosphorus and the fats. Cod-liver oil, 
the iodide of potassium, or the syrup of the iodide of iron, may be given 
alone or in combination. 

ANTERO-SPnSTAL PARALYSIS OF INFANTS. 

Synonyms. — Paralysie essentielle de I'enfance (Rilliet and Barthez); 
Infantile Paralysis (Radciiffe Volkman, and others) ; Paralysie atro- 
phique de I'enfance, Organic Infantile Paralysis (Hammond) ; Infantile 
Spinal Paralysis (Seguin) ; Spinale Kiuderlahmung (Heine). 

Definition. — This form of paralysis may be described as a condition 
usually characterized by a primary febrile stage, a secondary paralysis 
generally of the lower extremities, and a tertiary atrophy. The paralysis 
is incomplete, as sensibility is never lost. 

^ Diseases of the Nervous System, p. 225. 



278 DISEASES OF THE SPINAL CORD. 

Symptoms. — The disease is marked by a febrile onset of greater or 
less severity, attended by restlessness, malaise, and pains in the joints or 
back, and there may be rigors ; or in some instances the loss of motor 
power is preceded by one or more paroxysms of convulsions. This febrile 
state is by many mothers mistaken for " teething," " worms," or other un- 
important childish troubles, and it is not till the development of paralysis 
that any alarm is created. This symptom appears within two or three 
days from the beginning of the fever, and may take place at night. The 
only condition of disturbed sensibility is one of hypersesthesia, which, 
however, is not a constant symptom. 

Sinkler^ has collected a number of cases in which he has noted the form 
of invasion of the disease. He found that the paralysis took place sud- 
denly, that is, with prodromata in but 6 of 108 cases, while Dr. M. P. 
Jacobi^ noted this form of invasion in 12 of 163 cases that she had 
collected. The modes of onset are the following : — 

1. The child, while playing, suddenly drops palsied. 

2. The child may be paralyzed at night. 

3. Fever, but no convulsions ; rapid loss of power. 

4. Convulsions, followed by sudden paralysis. Sinkler reports but 
one case of this kind, and but two in which convulsions followed the par- 
alysis). 

5. The paralysis preceded by one for the exanthemata, or by whoop- 
ing-cough. 

6. Gradual development, perhaps limping at first, and afterwards com- 
plete paralysis, but no acute symptoms. 

In this exceedingly valuable lecture, Sinkler throws much light upon 
the symptomatology of the disease, and gives the details of a classical 
case. 

The paralysis may take the form of hemiplegia (Barlow and Duchenne 
have found cases of true cerebral hemiplegia, and Barlow has re- 
ported five such cases), or it may afiect the voluntary muscles of all four 
extremities, and some of those of the trunk ; but the facial muscles, as a 
rule, escape. After a short time there is a return of power in many of 
those at first involved, and but a small number of muscles (notably the 
anterior tibial, peroneal, and others of the leg and thigh) remain pow- 
erless. 

The temperature of the paralyzed muscles is much lowered, and there 
is sometimes a difierence of from eight to twelve degrees between the 
affected and normal sides. Heine considers the local reduction of tem- 
perature in old cases to be from ten to twelve and a-half degrees Fahren- 
heit. The bladder and bowels escape the paralysis, and their functions 
are consequently unimpaired. 

Muscular contractility is lost with the commencement of the paralysis, 
and the faradic current will rarely produce contractions. Such, however, 

1 Clinical Lecture, Med. and Surg. Keporter, March 10, 1877. 

2 Am. Journ. of Obstetrics, May, 1874. 



ANTERO-SPINAL PARALYSIS OF INFANTS. 279 

is not the case with the galvanic, except in extreme instances, or when 
the case is one of long standing. So far there are rarely any evidences of 
atrophy or contracture of the paralyzed muscles, but it will be found now 
that certain muscles at first affected begin to regain their lost functions, 
while others become atrophied and utterly useless. Even the galvanic 
current fails to stimulate them ; and at this period, which may vary from 
four to five weeks to six months from the beginning of the disease, there 
may be deformities and muscular contractures, which may result either 
from the weight of the body upon the affected limb, or from the anta- 
gonism of non-paralyzed muscles; but Volkmann^ considers that this in- 
capacity of the limb to support the superimposed load is of much greater 
importance as a cause of deformity than the mere antagonism of the unaf- 
fected muscles. 

The foot is apt to drop so that the toes hang limp and flaccid. 
Barlow alludes to the " talus pied creux," a deformity described by the 
French writer, the instep being prominent and the sole hollowed. 

Such deformities may take place as lateral curvatures of the spine, 
talipes, and other distortions which appear as various muscles are par- 
alyzed, or, if there be shortening of the limb (which is by no means un- 
common), as a consequence of reduction in the length and size of bones 
which have become atrophied. The deformities that may result from the 
disease under consideration are of a primary, and of a secondary or com- 
pensatory nature. The primary forms are those which are seen as talipes 
of both kinds, and result from loss of sustaining power of the muscles. 
The comjyensatory consist in spinal curvatures, such as lordosis or scoliosis.^ 
The skin is usually blue and livid, and the temperature is much below 
that of the healthy limb. These deformities rarely disappear, but con- 
tinue throughout life, which is in no way shortened by the disease. The fol- 
lowing cases may be presented to illustrate the appearance and behavior 
of the disease. The first case is somewhat anomalous, as there were two 
forms of paralysis ; the primary attack being hemiplegia, and the second- 
ary paraplegia. 

Case I. — Robert B. (a seventh -month child) was sent to me by Dr. 
H. G. Piffard, of this city. During September, 1876, he became fever- 
ish, and, after two days, during which he was confined to bed, he had a 
general convulsion. Before his fever he had eaten a great quantity of 
cherries, and his mother supposed his illness to be due to this cause. The 
mother stated that the convulsion lasted three and a half hours. He 
became paralyzed two days afterwards, the right arm and leg being af- 
fected ; but two days after this he could use even these limbs. A few 
days subsequently he went out to play, but came back feeling out of 
sorts ; and, afcer a few hours' fever, another spasm took place. Within 
the next thirty-six hours both legs were paralyzed, so that he could not 
stand. Towards the first of November he regained some power, and can 
now stand when holding a chair. 

1 Sammlung Klinisher, Vortrage, Heft 1, 1870. 

* Produced hj attempts to restore disturbed equilibrium. 



280 DISEASES OF THE SPINAL CORD. 

Present Condition. — He is a puny boy, about five years old, and is badly 
nourished. He has no voluntary power over lower extremities, but can 
move the arms perfectly. The legs are both very much reduced in size, 
and the muscles are flabby and atrophied. The peronei, solei, and ante- 
rior tibial muscles are reduced in size, and have lost their electric con- 
tractility. He perceives pinches, and changes of temperature, and the 
"wire-brush" produces much pain. The skin is cold, mottled, and dry, 
and here and there is dotted with patches of scurfy eruption. 

Case II. — Annetta F., aged 10 years. About three years ago she be- 
came quite ill after a sleigh ride, and it was supposed that she had 
" caught cold." Her feverish symptoms were quite decided, and she was 
slightly delirious. After several days she seemed to improve slightly, 
but on awaking one morning it was found that she was paralyzed and 
unable to rise ; and she complained of intense backache and tingling 
of the limbs, which, however, were of very short duration. About two 
months after this she began to recover the use of her arms, but the legs 
were more fully paralyzed ; and it was several months before she began 
to move her toes, and finally made feeble movements of a more extended 
character. The muscular contractions of the flexors were performed 
more easily than movements requiring extension ; and, after a time, she 
attempted to walk, but at first this act was impossible. During the next 
year she was obliged to use crutches, and needed the assistance of her 
nurse. When I saw her, there was talipes equinus varus of the left foot, 
while the right seemed to be but little affected. Flexion was possible, but 
extension of the leg or foot was beyond her power. There was some re- 
laxation of the ligaments of the knee-joint, so that when I made exten- 
sion I caused the tibia to form an obtuse angle with the femur, so that 
there was some anterior curvature. Her gait was peculiar, and she 
swung the left leg, bringing it down with a jerk. The skin covering the 
left leg was dusky and mottled, and seemed in close contact with the tis- 
sue beneath ; and the surface-temperature was several degrees below that 
of the other side. No rectal trouble. 

Case HI. — A girl sent to me by Dr. Lockwood, of Norwalk, had pre- 
sented, among other symptoms, mitral disorder, fever, general paralysis, 
residual paralysis, paraplegia, and paralysis and atrophy of the right 
deltoid, which cannot be made to contract when subjected to either cur- 
rent. Right leg more affected than the left. 

Case IV. — A girl 10 years of age. At the second year after a fall 
she became feverish, was delirious, and took to her bed. There was gen- 
eral paralysis of the right leg and thigh ; but after three months there 
was improvement, except of the leg, which remained paralyzed. There 
are now a pronounced talipes varus, complete atrophy of the anterior 
muscles, and utter loss of electro-muscular contractility. She has used 
various forms of orthopsedic apparatus without relief. 

Case V. — Frank N. C, 4 years old, a stout, rugged boy, enjoyed good 
health until January, 1877, when he contracted scarlet fever, with albu- 
minuria as a result. From this he recovered, but in August he again 
fell sick with what was pronounced to be rheumatic fever. There were 
high temperature, some diarrhoea, which lasted for a number of days, 
painful joints, and loss of power in both lower extremities. The power 
returned in the right leg, so that by the middle of September (three 
weeks from the invasion of the fever) he had control of that member. 
The left remains powerless, and there has been slow atrophy. The exten- 



ANTEEO-SPINAL PARALYSIS OF INFANTS. 281 

sors of the leg and foot are now powerless, and there is decided atrophy 
of these and the posterior tibial, abductors of the thigh and anterior 
muscles. The knee-joints are quite weak, and there are projections on 
the inner side of both knees. He is knock-kneed, no eversion or inver- 
sion of feet, but there is slight talipes of the left foot. 

Case VI. — Mamie W., 6 years and 1 month old, always was a nervous, 
excitable child. Has had several convulsions in her life of an epileptic 
character, without any after-effects, or apparent coexisting disease. In 
July last she had whooping-cough. On September 4th she was taken 
with colic, malaise, and convulsions, during which the body became rigid, 
and she frothed at the mouth. These convulsions appeared at 5 P. M., 
and lasted until midnight, She was unconscious all the time. At 7 P. M. 
the corner of the mouth became drawn up by spasms. She had fever 
during the following day and for a number of days. Did not make any 
attempt to move for a number of days, and for twelve days she could 
not speak. She was found to be generally paralyzed, and after a short 
time the arms recovered their strength, but the legs began to lose their 
size and shape, and became smaller than they were before. Her mental 
condition is defective (five weeks after attack). And, though there is no 
impairment of bladder or rectum, she does not call attention to her 
wants, but defecates and urinates in her clothing. Power of upper ex- 
tremities good. The legs are cold and mottled ; there is slight talipes on 
both sides ; and great wasting of the flexors of the feet, especially of the 
right. Faint contractions are excited by the strongest faradic currents, 
but she can move her toes very feebly, but not flex the foot. She has 
control over the thighs. Both feet are slightly everted. There is redness 
of the skin covering the right knee, but no pain ; no pain in back ; slight 
impairment of sensation, but reflex irritability not embarrassed, as was 
demonstrated by pinching; pupils moderately dilated. 

The muscles of the leg are more often affected than those of any other 
part. In nearly every instance the tibialis anticus is paralyzed, and in 18 
of the 23 examples I have noticed this muscle was affected. The ^jeroneus 
tertius, longus ; extensor es longi digitorum, proprius pollicis ; and the flex- 
ores longi digitorum, and longus pollicis, are usually affected. The deltoid 
is paralyzed more rarely, and of the cases I have enumerated there were 
but two in which this muscle was affected. The muscles of the upper 
extremities are seldom involved in comparison with those of the leg, and 
those that are usually paralyzed are the flexors of the hand. Though 
the muscles of the trunk may be sometimes involved in the early paraly- 
sis, it is extremely rare that we find any residual paralysis of any of 
them. Barlow and others have witnessed repeated attacks of paralysis 
in the same subject after apparent complete recovery. 

It is rare to find either arthritic enlargement or wasting, or bed-sores in 
uncomplicated essential spinal paralysis ; but this disease, which is limited 
to the anterior columns, should not be confounded with a transverse 
myelitis or compression myelitis that may be found among children which 
are not always clearly distinguished, and give rise to tissue changes. 

Causes. — The etiology of the affection is anything but clear. Expo- 
sure and bad or insufficient food are supposed to account for it, just as 



282 DISEASES OF THE SPINAL CORD. 

they do for many other diseases of the same class. Barlow alludes to 
the fact that an unrecognized form of exposure arises from taking a child 
into a sleeping-room with newly-plastered walls. It is a significant fact 
that more of these patients belong to the lower walks of life than to the 
higher, and that the children of the destitute poor, who come of drunken 
parents, and are " knocked about" and half-fed, are those who are gene- 
rally the victims of the disease. As to age, Sinkler has found that 84 of 
108 cases were between the ages of six months and three years, and that 
half of this number were males. Barlow,^ speaking of the infantile form, 
states that he found that there was no great preponderance of the disease 
in either sex, and that of 63 cases he had collected, 33 were males and 30 
females. His other statistics show that the disease more commonly be- 
gins before the second year, and that 42 of the 63 cases occurred between 
the first and second year of life. It will thus be seen that Barlow sup- 
ports the other authors I have mentioned. Of 53 cases in which the at- 
tack could be fixed with accuracy, 27 occurred in the months of July and 
August. 

Duchenne'-^ holds that two-thirds of the cases begin before the second 
year, which view I am disposed to take. Warm weather seems to favor 
the development of the disease, and in nearly two-thirds of Sinkler's cases 
the disease began in the months between May and October. Cases have 
been reported in which the exanthemata have preceded the paralysis, and 
varicella, measles, and scarlatina may be mentioned among these ; but it 
is probable that in the majority of such cases sclerosis not limited to the 
anterior columns has been, the central condition. 

Morbid Anatomy and Pathology. — We are indebted to Char- 
cot^ and Jofii'oy, Duchenne,* Echeverria,^ and others for reports of 
autopsies and microscopical examinations, and as the result of their in- 
vestigations the following appearances may be looked for. 

In the early stages of the disease there is probably a condition of sub- 
acute myelitis, with softening and destruction of nerve-elements, etc. This 
is confined exclusively to the anterior horns. Some of the nerve-cells of 
this portion of the cord are sometimes filled with granular pigment depo- 
sits, while others are disorganized and broken up. The nerve-tubes of the 
anterior roots will be found shrunken, the myeline absent, but the axis 
cylinder is nearly always intact. 

In other cases of longer standing there are evidences of atrophy of the 
anterior horns, perhaps amyloid degeneration, and sometimes sclerosis. 
The nerve-cells are found in an atrophic condition, or absent altogether. 
The white matter of the anterior and lateral columns is not rarely the seat 
of such degeneration, and proliferation of the connective tissue is some- 



^ On Kegressive Paralysis. W. H. Barlow, M. D., Manchester, 1878, p. 4. 
' De r Electrisation localisee, 3d ed., Paris, 1872, p. 417. 
' Archiv. de Phys., tome iii., 1870. * Ibid.*, tome iv., 1870. 

° Eefiex Paralysis, etc., p. 29, New York, 1866. 



ANTERO-SPINAL PARALYSIS OF INFANTS. 283 

times found. In 25 cases, collected by Seguin/ the constancy of the lesion 
is very clearly shown. 

The anterior horns together were affected in 11 cases. 

The right anterior horn alone was affected in 1 case. 

The left " " " " " 4 cases. 

Both affected in 6 " 

Sclerosis of antero-lateral columns (chiefly) and other white matter 13 " 

Tubercules and blood-clots 2 " 

Meningitis and meningeal congestion 2 " 

Damaschino^ and Roger, Cornil,^ Clarke,^ Charcot,^ and Joffroy have 
added many histories to those given to the profession by the early writers? 
and it is now well settled that the anterior horns and lateral columns are 
the seats of the central lesion. 

RosenthaP considers that the primary cause is dilatation and thicken- 
ing of the vessels, and does not believe that the morbid process begins by 
degeneration of the nerve-cells, Notwithstanding the appearance of well- 
defined lesions in nearly every case, there are occasional examples of the 
disease where no central changes are to be found. Ketli ^ reports one of 
these in which extensive muscular alterations were visible, but not the 
slightest indication of central disease. Elischer^ examined the muscles, 
which were seen to be the seat of both fatty and colloid degeneration. 
The sarcolemma and nerves were not altered. In the striated muscles, 
instead of the single normal cell-nucleus, there were seen three or four 
granular cell-nuclei, which seemed to 'be at the same time enlarged, and 
contained two or three, or even more nucleoli. The coutractile material 
was diminished, so that it did not fill out the sheath, but drew away from 
it. This atrophy was so great that at the upper and under part of the 
spindle-shaped cell-nucleus of the sheath there was hardly to be found a 
breadth of .002 millimetre of cross-striped contractile muscular substance. 
Ketli thiuks that these changes in the muscle without central disease point 
to the peripheral nature of the affection, in which opinion he has but few 
followers. Lesions of peripheral nerves have been found by various ob- 
servers. Riuecker ^ reports an autopsy, made by Forster, in which these 
nerves were found to be thin, shrunken, and greatly degenerated. The 
bones and muscles present appearances which are perhaps more interest- 
ing than those of the cord. 

The muscular fibres are at first found to be reduced in size, and subse- 
quently the transverse striae gradually disappear, while the longitu- 
dinal fibres become more marked. There is increase in the connective 
tissue, and next a fatty degeneration, the oil-globules taking the place 

^ Spinal Paralysis, etc., pp. 12-13. 

2 Gaz. Med. de Paris, 1871. ^ ji^i^., 1864, p. 290. 

* Med. Chir. Trans., vol. ii., 1869, p. 249. 

5 Op. cit. 6 Quoted by Fox, op. cit„ p. 290. 

' Ibid. 8 Ibid. 

» Jahrs. fiir Kinderheilkunde, 1871, 5 Heft 1. 



284 



DISEASES OF THE SPINAL COED, 
Fig. 38. 






I ',,* ^ 



( ^ ivv - J 



N^\>*i>'~^f^ 



a. Normal fibre. 
A. Represents the normal fibres with well-marked transverse striae. B. The transverse strise 
are not quite so distinct, but the longtitudinal fibres are well marked. 



Fig. 39. 



Fig. 40. 



■r^ - ' '^'^^^ 



l 







a. Fat cells, b. Interstitial fatty deposits. 

The stage of fatty degeneration. A. The lon- 
gitudinal fibres are only seen, and there is a de- 
posit of round and oval adipose cells and oil-glo- 

ules. B. Undulations of longitudinal fibres. 



a. a. Fat molecules. 

The progressive fatty degeneration 
and the disappearance of longitudinal 
fibres. 



Fiff. 41. 



k. 



This illustration represents tlie final stages, in which it will be seen that the muscular fibre has 
lost its identity, and at last there is an absence even of oil-globules. 

of the normal muscular tissue, and finally nothing remains but the con- 
nective tissue and fat, which latter disappears, leaving the sarcolemma 
bound together by connective tissue. 



ANTERO-SPINAL PARALYSIS OF INFANTS. 285 

The accompanying cuts, from Dachenne, show the changes that take 
place. 

The blood vessels running to the atrophied muscles are often of smaller 
size than they should be, and sometimes are the subject of atheromatous 
degeneration. 

The bones also undergo atrophic changes, becoming friable and thin, 
and occasionally the seat of fatty degeneration. The cartilage covering 
their articular extremities is roughened, and in some places detached. 

Though some observers have maintained the peripheral origin of the 
disease, the large majority have adopted Heine's original views advanced 
in 1840, and endorsed by Duchenne in 1855. The almost general opinion 
that the disease is of central origin has been conclusively proved, I think, 
by the large number of autopsies, the most valuable of which have been 
made in late years. 

Westphal's views in regard to the existence of trophic cells, which were 
also adopted by Duchenne, certainly receive decided confirmation in the 
constant atrophic processes which are connected with degeneration of the 
cells of the anterior horns. 

That it is not a disorder dependent upon the sympathetic system has 
been proved by the utter absence of any diseased condition either of the 
ganglia or the nerves. 

Diagnosis. — The existence of febrile symptoms, and the secondary 
complete paresis which changes its character and is finally confined to a 
few muscles, the unimpaired sensibility, and the rapid sequence of 
atrophy and deformities give this disease a distinct character which does 
not admit of any mistake in diagnosis. Forms of reflex irritation, such 
as ascarides, adherent prepuce, and like peripheral conditions may pro- 
duce some of the symptoms, but their non-progressive character, and dis- 
appearance with the removal of the cause, should make the possibility of 
an error very remote. 

Prognosis. — Much depends upon the behavior of the muscles under 
electrical stimulus. If the least response either to the galvanic or faradic 
currents can be recognized, the chances are extremely good, and it only 
remains for the physician to be patient and attentive. In regard to dura- 
tion and its bearing upon prognosis, I may state that many cases have 
been cured even after deformities have taken place. Klopsch,^ of Bres- 
lau, reports several of these cases. In one there was shortening of the 
thigh and deformity of the pelvis, as well as other serious troubles. Much 
of the hope of cure, however, depends upon the care taken in the treat- 
ment. 

Treatment. — The most active and useful agent in the therapeusis of 
this disease is undoubtedly electricity, either as galvanism or faradism, 
applied to the muscles. The treatment of the central lesion is also of 
importance, and it is advisable to begin an energetic course of ergot, 
with the actual cautery, before the atrophic condition commences. 

^ Ullsburger's Prize Essay, Am. Journ. of Obstet., 1870-71. 



286 DISEASES OF THE SPINAL CORD. 

After this the central disease is very difficult to manage. Heine recom- 
mended strychnine, which, in young children, may be given in doses of 
xioth of a grain, and afterwards increased. Cod-liver oil and sea-air, good 
food, and tonics are of as much importance as anything else. 

When we come to the treatment of the paralyzed muscles, we may try 
electricity, massage, hypodermic injections of strychnine, and the applica- 
tion of heat and cold. If the faradic current be found to be incapable of 
producing contractions of the paralyzed muscles, we must make use of the 
galvanic. From ten to thirty^ cells of any good galvanic battery should 
be employed, and the electrodes must be covered with sponge or cloth. 
When the positive electrode is placed in the groin (if the legs are 
paralyzed), and the negative over the muscle or muscles paralyzed, a con- 
traction may be seen ; if such does not take place, the current may be 
slowly intermitted by proper apparatus, or by simply removing the sponge 
from the surface and reapplying it again. If the current be too strong, or 
if the application be too protracted, we may be disappointed, for the small 
amount of electric irritability that exists may be quenched before an ap- 
preciable contraction is perceived. It is therefore better to use a current 
of low tension. If we are gratified by the appearance of a contraction, we 
should produce two or three more and then stop for the day. By increas- 
ing the muscular stimulation little by little each day, we may finally create 
powerful contractions with a minimum current, and after a short time we 
may substitute the faradic current. It is of great importance that muscu- 
lar relaxation should be produced during the use of electricity. I may 
repeat what I have already said, and add that a tired muscle naturally 
responds less perfectly to electric stimulation than one which is unim- 
paired. If massage is used, it is well to knead and rub each muscle every 
day. 

Should electricity fail to relieve the contracted condition of the limbs, 
which may be present, we may avail ourselves of the knife. Tenotomy 
is often of service, but it should not be prematurely resorted to, but left 
as a last resource when all other remedies fail. Various methods for im- 
proving the temperature of the paralyzed limbs have been described by 
Eoth.' 

In brief they are the following : — 1st. The position should be attended 
to in all cases; a paralyzed part should not be permitted to hang down, 
and to dangle about ; it should be placed in a horizontal position, and the 
coldest part should be the highest, which assists the refiiex of venous blood. 

2. Clothing. — Spun silk, a mixture of silk and wool, wool or fur gar- 
ments should be worn next to the skin ; it is only in exceptional cases 
that the hypersesthesia of the cutaneous nerves does not permit any of 
these materials to be used. Here silk is placed next to the skin, and wool 



1 It will rarely be found necessary to use this number, and it is advisable to begin 
with the weakest current that will provoke contractions. 

2 On Paralysis in Infancy, Childhood, and Youth. London, 1869, p. 83, oh. 62, 
quoted by Barlow. 



ANTERO-SPIXAL PARALYSIS OF ADULTS. 



287 



or fur over it. The paralyzed part should be well warmed before it is 
covered with bad conductors of heat. Hoth recommends also exposure 
of the leg to direct heat of the fire, a screen with a hole for protection of 
the rest of the body to be provided. He also recommends the use of 
Turkish baths, the application of a bag filled with hot salt or sand, and 
the usual form of massage and electricity to which I have before alluded. 
Volkman speaks in glowing terms of the use of Junot's boot, which, 
with the rubber muscle of Sayre, and the plaster bandage, is a useful 
form of treatment in cases of long standing. The paralyzed limb is placed 
in the boot and the air exhausted, so that a determination of blood to the 
part shall be induced. 



Fig. 42. 



Ajstteko-spixal paralysis of adults. 

Synonyms. —Acute anterior spinal paralysis. Subacute general 
anterior spinal paralysis (Duchenne). Spinal paralysis of adults (Meyer, 
Charcot, Gombault). Myelitis of the anterior horns 
(Dujardin-Beaumetz, Seguin). Acute spinal pa- 
ralysis of adults (Petitfils). Anterior poliomyelitis 
(Erb, Eisenlohr). Acute anterior poliomyelitis 
(Kussmaul). 

Definition. — A myelitis of the anterior horns 
of the spinal cord, either symptomatized by an 
acute invasion attended by fever, and followed by 
sudden paralysis, or by the gradual appearance of 
the paralysis which becomes complete and next par- 
tially disappears, leaving certain muscles afiected ; 
unattended by loss of sensation, or vesical and rectal 
trouble. 

Symptoms. — I am indebted to the little me- 
moir of Dr. E. C. Seguin for assistance in the prepa- 
ration of this article, and for the report of a case 
which afterwards fell under my observation when I 
followed him as visiting physician to the Epileptic 
and Paralytic Hospital. Duchenne^ first called 
attention to this form of paralysis as early as 1853, 
and recognized its identity with infantile paralysis. 
In 1863 Charcot^ was struck with the similitude be- 
tween the two diseases, and in 1872-73 and later 
years Gombault/ Dujardin-Beaumetz,* Petitfils,^ 
and Bernhardt ^ have presented cases, and decided the fact that infantile 




Antero-spinal Paralysis. 
(Seguin). 



1 De r Electrisation localis^e, Paris, 1872, p. 437 et seq. 

2 Papers of Petitfils. 

^ Archiv. de Physiol, norm, et path., 1873, pp. 80-87. 

^De la myelite aigiie, Paris, 1872. 

^ Consideration sur I'atrophie aigiie des cellules motrices, Paris, 1873. 

^ Arch, fiir Psvch. und Nervenkrank, 1874. 



288 DISEASES OF THE SPINAL CORD. 

paralysis had an analogue in adult life. Gombault brought forward the 
first case with an autopsy confirming the theory enunciated by Duchenne, 
and in this country the admirable little works of Seguin epitomizb all that 
has already been brought forward. The first case seen by Seguin ^ has 
since fallen under my observation, and from his published notes I copy 
her history. 

Female, unmarried, aged twenty years. Admitted to the Epileptic and 
Paralytic Hospital, Blackwell's Island, service of Dr. E. C. Seguin, No- 
vember, 1871. Patient presents a paralyzed and extremely atrophied left 
leg, and gives the following imperfect history : The trouble began nine 
months ago, suddenly during sleep, with painful contractions ; she then 
gradually (?) lost power in the left leg ; no other limb affected. The 
patient cannot state how long a time elapsed between the first symptom 
and the discovery of palsy. She adds that, on the day before the attack, 
her left leg felt quite cold and a little numb ; and that her menses were 
suppressed. No cause is apparent — no hereditary influence, no injury. 

Examination : Left foot is drawn up in moderate pes equinus, with in- 
ward inclination. No voluntary movements below the knee. The pa- 
tient's answers to the sesthesiometer test are unreliable ; sensibility to 
painful impressions is somewhat impaired, that to temperature preserved ; 
tickling is felt equally on both feet. Pressure shows tenderness over the 
lumbar vertebrse ; no spontaneous pain. The right calf measures 26.9 c. 
in circumference, the left 23.7 c. There is absolute loss of electro-mus- 
lar contractility in all the muscles of left leg. The left leg is very cold, 
and its circulation feeble. I frequently called the attention of the resident 
staff and of friends to this remarkable case as one of the same kind as 
that which, occurring in the early years of life, we call infantile spinal 
palsy. 

The subsequent history need not be reported. No treatment did any 
good ; the girl remained in the hospital without any acute symptoms, and 
went away October 3, 1873, carrying this wasted left leg. She was em- 
ployed as a help in the wards of the Convalescent Hospital on Hart's 
Island, and was there much exposed to cold. 

The second attack, of which patient gives a good account, came on late 
in December, 1873. Had pains " like rheumatism " in right leg ; there 
was a feeling of pins and needles in the limb, this numbness extending 
above the knee. She is positive that on the fourth day the right leg was 
completely paralyzed. No symptoms in left leg. No bedsore, and no 
affection of bladder or rectum. Ke-admitted to the . Epileptic and Para- 
lytic Hospital, March 3, 1874, with atrophy and palsy of both legs ; no 
acute symptoms. 

During the spring and summer this patient rather gradually lost 
strength in the thighs, in the right most. She also exhibited a variety of 
interesting visceral disturbances, consisting of amenorrhoea, lasting two 
or three months ; the menses then appearing with much pain, the blood 
abundant and in clots ; there were also pains in the back and lower ab- 
domen. On many days in this period the urine had to be drawn off with 
the catheter, and it often was bloody, exhibiting a heavy mucous deposit, 
and containing albumen. The microscope showed only leucocytes and a 
variety of epithelial cells — there being probably both pyelitis and cystitis . 

1 Spinal Paralysis, N. York, 1874, and Anterior Myelitis, 1877. 



ANTERO-SPINAL PARALYSIS OF ADULTS. 289 

Since the middle of September has not required the catheter, and, with 
exception of palsy, has been better. 

Ke-examined October 25, 1874. Patient, when she first came in this 
year, walked ill with a crutch and stick ; is now able to walk with two 
sticks (result of education). Cannot stand or walk without help. The 
patient is a stout and healthy girl, exhibiting nothing abnormal above 
the hips. Both lower extremities are extensively palsied and much 
wasted. The left leg (first attacked in 1871) shows no voluntary move- 
ment below the knee, with exception of slight separation of the toes. As 
the patient lies on the bed she is able to raise the extended limb as a 
whole ; but the strength at knee-joint is small. The thigh is thin and 
flabby ; the leg is the seat of extreme atrophy, and looks just like the 
same part in cases of infantile spinal palsy, there being apparently only 
connective tissue and fat around the bones, the skin being bluish and 
very cold to the touch. The right lower extremity (paralyzed in 1873) 
is in a very similar though less extreme state. All voluntary move- 
ments are possible with the foot, though they are feebly performed. The 
limb, as a whole, cannot be raised from the bed, and flexion at knee-joint 
is weak. The quadriceps extensor femoris is wholly paralyzed ; the 
flexors of the thigh upon the body act feebly ; the adductors fairly. 
Both feet lie extended and adducted ; toes flexed. The right leg is, 
like the left, extremely wasted, bluish and quite cold. Sensibility to 
contact, pain, and temperature are preserved in both limbs. Tickling 
is felt, but produces no reflex movement in the palsied parts. The 
electro-muscular reaction of the atrophied muscles of both limbs is lost 
(both currents). At present, urine is passed normally. The patient's 
arms, shoulders, and chest are large and rounded, standing in remarkable 
contrast to the dwindled legs. There have been no bedsores and no 
spinal epilepsy. 

Circumference of right thigh (lower third) 31.5 c. . 

" left " " " 30.5 

right calf 24.0 

left " 21.5 

'' forearms 25.0 

On a healthy girl (non-palsied) of same proportions as the patient, the 
following measurements are obtained : — 

Circumference of right calf 35.0 c. 

left '' 34.5 

" .forearms 24.0 

The patient having been in bed some time, well covered up, has a 
thermometer held between the great and" second toes of each foot for 
three minutes, with results : — Eight side, 84.25° Fahr. ; left side, 86° 
Fahr. 

In March, 1876, the patient came under my charge, when I found that 
her condition was somewhat aggravated. She manages to go about with 
the aid of crutches, but has utter loss of power below the knees. The 
tactile sensibility is much lowered, and tickling can be borne without any 
reflex movement being produced, and she has lost control to a great ex- 
tent over the bladder and rectum. 
19 



290 DISEASES OF THE SPINAL CORD. 

Another case reported by Lincoln is well worth presenting, as illustra- 
tive of this form of disease beginning without fever. 

A tall, stout man/ 49 years of age and of previous good health, noticed 
one morning, without any previous symptoms, a feeling in his legs as if 
they had fallen asleep. The feeling came on again and again through 
the day, and he began to be a little weak in the legs. In the afternoon, 
when trying to step upon the platform of a street car, he failed, and had 
to be helped in. On arriving home, he was able (with assistance) to walk 
up stairs to his bedroom, and went to bed, where he remained. 

When seen by Dr. L., two days later, he felt well, no giddiness, mus- 
cles of face and eyeballs under perfect control, pupils normal in size and 
contracted well, speech natural, vision and hearing without defect. The 
bladder and rectum performed their functions normally. The senses of 
touch, pain, and temperature were normal in the hands, and nearly so in 
the feet. Reflex contractions could scarcely be obtained from the soles. 
There were no abnormal sensations. Pulse, 80 ; temperature, 98°. No 
albumen in the urine. 

The muscles of the neck and limbs, except below the knees, were gene- 
rally in a condition of semi-paralysis. He lay on his back almost help- 
less ; could not raise his head from the pillow without some help, and 
could not raise his knees from the bed by flexing the thighs. The grasp 
of his hand was very feeble indeed. There was no paralysis of any mus- 
cle. Below the knees he seemed to have more strength. The weakness 
was much more marked on the left than on the right. 

Treatment consisted at first in nux vomica and cinchona, and subse- 
quently tincture of iron with strychnia, and Horsford's acid phosphates of 
lime and magnesia. On the fifth day of the attack, treatment by the 
induced electric current was begun, when it was found that some at least 
of the muscles had lost part of their susceptibility to this stimulus. The 
loss went on increasing until the twenty-first day, when the galvanic cur- 
rent was substituted, a descending current being applied to the spine, and 
interrupted currents to the muscles, three times a week; the faradic cur- 
rent was also continued for a few weeks. 

The hot-air bath to profuse perspiration was used just before the appli- 
cation of the currents, together with regulated gymnastic exercises. The 
paralysis of the muscles was gradually relieved under this treatment to a 
very considerable degree. The patient's improvement was very gradual, 
and it was six months before he was able to ride out. He finally was en- 
abled to attend to his business pretty much as before the attack. 

Other cases begin much more slowly, and several of this kind are re- 
ported by Duchenne, but the origin of the disease is nearly always sud- 
den. There may be pain or dyssesthetic symptoms, or no warning at all, 
the patient awaking in the morning and finding himself paralyzed, as 
was the cas3 with Seguin's patient. Like the infantile form, there may 
be an acute attack of fever, which may last for several days, during 
which there is usually delirium or rigors. The paralysis appears during 
this time, and may be general, so that the upper and lower limbs are af- 
fected and the loss of power is complete. The functions of the bladder 

1 Boston Medical and Surgical Journal, March 25, 1876. 



ANTERO-SPINAL PARALYSIS OF ADULTS. 291 

and sphincter ani are always normally performed until other parts of the 
cord are affected, and there is neither incontinence of urine nor involun- 
tary evacuations. At the end of a few weeks there is a commencing im- 
provement, some of the muscles regaining their lost power and contracting 
quickly under electric stimulus, while atrophy of those already paralyzed 
begins to take place. The skin over the paralyzed limb is quite cold and 
blue, and there is diminution of temperature and faradic excitability, 
while ultimately it is impossible to provoke any response, and the limbs 
become deformed and twisted. Atrophy of deeper parts follow, and the 
bones become reduced in size, while the articular ends appear large in 
contra$t with the attenuated size of their shafts. Sensibility is rarely 
disordered, though exceptional cases of anaesthesia or hyper^esthesia are 
met with, but after the inflammation has involved the posterior columns 
the phenomena of general myelitis are presented. Dysjesthesise are com- 
mon, and the patients complain of subjective cold, various pains, and the 
waist-constricting band. The muscles of the face, neck, chest, and abdo- 
men are rarely affected, but the extremities remain deprived of pain after 
there has been a considerable retrocession of the original complete paral- 
ysis. The atrophy is rapid, and differs from that of progressive muscu- 
lar atrophy in the fact that whole groups are affected at a time, while the 
peculiarity of progressive muscular atrophy is that muscles are irregu- 
larly afftcted. There are never bedsores. 

The disease may be so rapid in its development as to suggest the mal- 
ady known as acute ascending paralysis, and it is probable in such case 
that the extension of the disease proper is not always confined alone to 
the anterior columns. 

Erb ^ alludes to a light variety of spinal paralysis, which has been de- 
scribed by Kennedy, Fry, and others. To this variety has been given 
the name '' temporary spinal paralysis." The paralysis is characterized 
by its brief duration, and may involve a limited group of muscles or seve- 
ral groups. It would seem, therefore, that there are two varieties : the 
temporary and permanent ; but Seguin and others have made the classifi- 
cation acute, subacute, and e/iroTiic, which is based rather upon the variety 
of myelitis than the paralysis. Ducheune applies the term sub-acute 
to the former, which begins without fever, attacks the lower extremi- 
ties first, and, extending upwards, involves the muscles of respiration and 
deglutition. 

Causes. — The same unsatisfactory history of exposure, fatigue, and 
peripheral irritation is connected with the history of this as well as other 
spinal diseases. In four of Seguin's cases surface exposure to cold is said 
to have produced the attack, and in three other cases, " refrigeration " is 
named, while in others dysentery, measles, and other acute diseases were 
at the origin of the trouble. 

As regards age and sex, I can do no better than refer to the tables of 
Seguin. All of the patients whose histories he collected were of middle 

1 Archiv. fiir Psychiatrie, Band v., Heft 3. 



292 DISEASES OF THE SPINAL CORD. 

age. " The greatest age at the time of seizure was 62 years, the least 18 
years." Among 17 cases reported by various observers, there were 13 
men and 4 women. 

Morbid Anatomy and Pathology. — But very little light has 
been thrown upon the morbid anatomy of the cord, which accounts for 
this form of paralysis. Chalret ^ and Gombault ^ have reported two cases. 

The appearances found may be briefly enumerated as these : The hori- 
zontal fibres which pass from the anterior horns to form the anterior 
spinal nerve-roots were diminished in size, and the large ganglion -cells of 
the anterior roots were atrophied, having undergone yellow pigmentation. 
Some of the nerve-cells which had not undergone this form of degenera- 
tion, were also reduced in size. This information is very meagre, 
though these two cases illustrate the pathological anatomy of the dis- 
ease. Charcot and the majority of observers believe that the situation 
of the lesion is always in the anterior horns. The only matter of dis- 
pute seems to be whether or not there is primary degeneration of the 
cells, or an acute interstitial myelitis and secondary injury of the nerve- 
cells. This latter view is held by Erb,^ and, I think, is being generally 
adopted. 

The muscles were found to be in a state of fatty granulation, which is 
the case in the infantile variety. In some respects the disease resembles 
progressive muscular atrophy and bulbar paralysis, the lesion being atro- 
phy of the motor and trophic cells, but it is probable that the trophic 
cells are primarily affected in these latter diseases. 

Diagnosis. — Antero-spinal paralysis is likely to be sometimes mis- 
taken for progressive muscular atrophy. If we bear in mind its sudden 
or almost sudden and complete origin ; the absence as a rule of fibrillary 
tremors (only two cases which presented these symptoms having been re- 
ported) ; that the paralysis precedes the atrophy, and retrocedes after the 
first general attack ; that electric irritability is primarily lost ; and that 
the atrophy involves the muscles of one or more (usually two) extremi- 
ties, there need be no error made in diagnosis. Anaesthesia, incontinence, 
and paralysis of the sphincter ani prevent it from being confounded with 
general myelitis, these symptoms belonging to the latter in addition to the 
loss of power and atrophy. Spinal congestion may sometimes give rise to 
some of the symptoms, and Cartwig* presented a case which he called 
"intermittent," somewhat resembling the lighter form of true antero-spinal 
paralysis. 

A sugar-baker, aged 23, who was exposed to great heat and sudden 
changes of temperature while very lightly clothed, had suffered in his 
eighteenth year for four or five weeks from an attack of tertian ague, 
from which he recovered. One day he perceived a numbness in his legs, 
which rapidly attacked his arms also, and finally led to complete para- 

1 These de Paris, 1872. 

2 Archives de Physiol., norm, et path., tome v., 1873. ^ Op. cit. 
* Centralblatt f. d. med. wis., June 15, 1870. 



ANTERO-SPINAL PARALYSIS OF ADULTS. 293 

lysis of the muscles of the neck. Speech, deglutition, and respiration 
were somewhat impeded ; the muscles of the eye were unaffected, as were 
also the alvine and urinary excretions, and sensation. After twenty-four 
hours there was a remission of the symptoms ; first the neck began to 
become movable, then the fingers, arms, body, and finally the legs. All 
this took place in half an hour, and was followed by an increase of per- 
spiration. During the next twenty-four hours the patient remained free 
from paralysis, but was dull ; after which, the above-described symptoms 
returned. The brain was always free ; the cervical portion, especially 
the upper, was not always equally affected ; the movements of the neck 
were often free ; and difiiculty in deglutition and respiration, inequality 
of the pupils, and myosis, were frequently present. The phrenic nerve 
was always unafiTected. When there was not complete paralysis, the 
affected limbs were generally stiff, and there was contraction of the pre- 
dominating groups of muscles ; when complete paralysis was present, the 
muscles were soft and flabby. Electro-muscular irritability was almost 
completely absent during the paralysis, and the violence of the muscles 
varied. Under the use of quinine, the patient's condition was on several 
occasions quickly improved, but he was not cured. He was under obser- 
vation for more than six months. The author believes that the case was 
one of masked intermittent, and that the phenomena were due to hyperse- 
mia of the cord and occasional increase of serous exudation. 

In spiual congestion there are no deformities, no atrophy, and nearly 
always vesical trouble and constipation. 

Acute ascending paralysis resembles very closely certain forms of the 
disease under consideration. In one remarkable case reported by Des- 
jerine,^ no morbid appearances were found after death. A man entered 
the hospital suffering from undefined pain in the lower limbs, and 
two days after became paraplegic without any loss of sensibility. The 
paralysis rapidly succeeded, and, after four days, he died ; no trace of 
disease after paralysis of the respiratory muscles could be found except 
dilated vessels. 

Seguin considers that this involvement of the respiratory muscles is a 
diagnostic sign. 

Prognosis. — Antero-spinal paralysis is not a disease which is rapidly 
fatal, and many cases recover within a short time after the beginning of 
the attack. I am not disposed to think that the lesion is an ascending 
one ; but rather that, if it progresses at all, it involves the posterior and 
laterial parts of the cord in the majority of cases, and does not spread 
longitudinally. This is probably the condition of affairs in the case of 
S. W. Should the paralyzed muscles become atrophied to such an extent 
that deformities result, I think that there is very little hope for the 
patient. If, however, the muscles can be made to respond to the galvanic 
current, we should never be discouraged. 

Of the cases reported by Duchenne, Meyer, Bernhardt, Seguin and 
others, I find that of 16 cases there were but 2 deaths. In one observation 
there was improvement in six months, in another in four, and in others two, 

^ Archives de Physiol., etc., June, 1876. 



294 DISEASES OF THE SPINAL CORD. 

three, eleven, and twelve. In two cases the patients were cured, and in 
several there was progressive unfavorable advancement. 

Treatment. — In electricity we possess a remedy of the greatest 
value. I have already called attention to its use in the infantile form of 
the disease, so there is no need for going into details. It is well to use 
both the galvanic and faradic currents, and in the acute form of the trou- 
ble we should begin with counter-irritation of the spine as early as possi- 
ble, and for this purpose may employ blisters or the actual cautery. 

Ergot and belladonna in rather full doses should be employed in con- 
junction therewith. Seguin recommends leeching and dry cups, which 
are both excellent. 

Should the pain be severe, we may use morphine by means of the hy- 
podermic syringe ; or spinal galvanization. The after treatment should 
be with the galvanic current. 

The use of warm applications, such as have been spoken of as of benefit 
in the infantile variety, are worthy of trial. 



PKOGRESSIVE MUSCULAR ATROPHY. 295 



CHAPTEE X. 

DISEASES OF THE SPINAL COED (Continued). 
PROGRESSIVE MUSCULAR ATROPHY. 

Synonyms. — Wasticg palsy ; Cruveilhier's paralysis ; Progressive 
miiskelatrophie ; Progressive muskellahmung. 

Definition. — This is an essentially progressive atrophy of certain 
groups of muscles. It is not preceded by any paralysis, but followed by 
loss of power, and terminates usually by involvement of the respiratory 
nerve-centres. 

Cooke,^ in 1795, directed attention to a condition he called " anomalous 
hemiplegia," which was clearly progressive muscular atrophy, and his 
was probably the first recorded case. Bell,^ Abercrombie,^ and Darwell* 
each published cases which were undoubtedly of this kind; and, in 1836, 
Mayo ^related two cases. It was not, however, till 1849, when Diichenne 
de Boulogne^ presented a memoir to the Institute of France, entitled 
" Atrophie viusculaire avee transformation graisseuse," that the present 
disease. was recognized. In 1853, Cruveilhier^ described some cases in 
which the atrophy was general, all the voluntary muscles being afiected. 
In 1850-1861, Aran,^ Duchenne,^ and Eisenmann^° brought forward ad- 
ditional facts, and the latter agreed with Cruveilhier that the " nerves 
or nervous centres are at fault anterior to the muscles, and that the 
atrophy of the latter is a secondary process." Since that time we are in- 
debted to Roberts ^^ and Friedreich ^^ for most clear and instructive de- 
scriptions. 

Symptoms. — The appearance and progress of the disease are most 
gradual. The affected individual may first notice a slight weak- 
ness in one of the upper extremities. Perhaps the first indicattion of 
trouble which suggests to the patient the commencement of the 



1 Cooke on Palsy, p. 31,1822. 

2 The Nervous System of the Human Body, London, 1830. 

3 On the Brain and Spinal Cord, p. 419, Edin., 1828. 
^ Lond. Med. Gaz., vol. vii-, p. 201. 

5 Outlines of Human Pathology, p. 117, London, 1836. 

6 Memoires de I'Acad. des Sciences, 1849. 

7 Archives Gen. de M^d., May, 1853. 

8 Ibid., Sept., 1850. 

^ De 1' Electrisation localis^e, Paris, 1855-61. 

10 Canstatt's Jahresbericht, 1859. 

11 An Essay on Wasting Palsy, London, 1858. 

12 Ueber progressive muskelatrophie, etc., Berlin, 1873. 



296 



DISEASES OF THE SPINAL CORD, 



disease, is when the act of writing is attempted. According to Eoberts, 
the disease begins, in two-thirds of the cases, in the upper extremities, 
and the muscles of the hands are the first to suffer loss of functioti. Very 
often several muscles are aifected together, and they soon become agitated 
by what are known as fibrillary contractions, or, as they have been called, 
vermicular contractions, which in their nature are probably a divided re- 
flex excitation. The subcutaneous contraction of muscular filaments sug- 
gests the appearance of worms crawling beneath the skin, and there is 
sometimes a species of muscular shivering. These fibrillary contractions 
may be excited by sharply striking the muscles with a ruler on the hand, 
and they sometimes follow the passage of the galvanic current through 
a nerve-trunk. As I have said, the hand may be afiected first, and 
there may be extensive wasting here before other parts are attacked. The 
muscles of the palm of the hands, when atrophied^ give to that member 
a most unsightly appearance. The bones stand out in strong relief, and 
the thenar and hypothenar eminences are flattened, and the flexor ten- 
dons are prominent, and increase the deformity. With this there is con- 
traction of the flexors, and the hand resembles more the claw (Fig. 43) 

of an animal than anything else, so that it 
(Fig. 43). has been called "main en griffe." The 

back of the hand also presents a most skele- 
ton-like aspect, the extensors, the interossei 
muscles, and sometimes the adductors of the 
thumb having been reduced in size. The 
forearm and arm are next to follow, and 
rapidly lose their normal conformation. The 
deltoid and serrati muscles may be involved, 
while those of the arm proper may occasion- 
ally be passed over. The head of the hu- 
merus and angle of the scapula are quite dis- 
tinct, and this bone may be drawn out of 
place by the healthy muscles, this being the 
rule when the serratus magnus is the seat of 
atrophy. The angle of the scapula is drawn 
"main en griffe*' (Duebenne.) upwards and inwards, and Etands out from 
the trunk. It is rare to find symmetrical atrophy, and in the majority 
of cases I have seen there has been a great diflerence in the invasion of 
muscles on the two sides. The right upper extremity appears to be the 
favorite seat of the atrophy, while the lower extremities are quite rarely 
affected, and in the proportion of 1 to 12 to the upper extremities. The 
muscles of the face and head are sometimes the seat of atrophy, but this 
is unusual, though muscles may occasionally be so extremely wasted that 
there is no appearance of intelligence whatever. The eyes, of course, 
being unaflected, are the only agents of expression. There may be atro- 
phy of the tongue and buccal muscles, with disturbances of speech and 
drooling of saliva, and in such cases death usually follows in a very short 
time. Sometimes the muscles of the neck do not escape the extension of 




PROGRESSIVE MUSCULAR ATROPHY. 297 

the disease, and the chin falls forwards and downwards. The last mus- 
cles involved are generally those concerned in respiration ; and not only 
are the intercostals the subjects of such a change, but the diaphragm is 
finally paralyzed, so that the action of the lungs is interfered with, and 
ultimately the patient is literally asphyxiated. Subsequent to atrophy, 
a loss of power takes place. The affected muscles preserve for a long 
time their electric contractility; but this is finally lost as they decrease in 
size, and loss of power increases till finally the patient becomes helpless. 
Duchenne is of the opinion that the loss oi voluntary muscular contractil- 
ity is rather the consequence of atrophy or textural alteration than of 
paralysis, i. e., loss of motor innervation (" C'est-a-dire du defaut d'action 
nerveuse motrice"). Tactile sensibility is, however, rarely blunted. One 
of the earliest symptoms of progressive muscular atrophy is the presence 
of dull pains in the afiected limbs, and this has led very frequently to a 
mistake in diagnosis, the condition being often considered rheumatic. In 
one case sent to me by Dr. E. G. Loring, I found that the atrophied mus- 
cles were the deltoid, serratus magnus, and biceps, but none of the lower 
muscles of the forearm were attacked. The man had consulted another 
physician, who considered the case one of chronic rheumatism, and pre- 
scribed liniments and alkalies. The patient was an upholsterer, and had 
been obliged to use his right arm to a great extent, especially in ham- 
mering on cornices, and putting up decorations which were above his 
head. He had had violent pain in the shoulder for some months, and 
subsequently the atrophy began in the deltoids. When I saw him the 
head of the humerus was prominent, and there were fibrillary contrac- 
tions in some of the muscles of the back. When the upper extremity is 
affected, it will be found that when the forearm is flexed the belly of the 
biceps will be often found to be reduced to the size of a small ball. The 
progress of the disease is marked by the occurrence of well-marked inter- 
missions, and a year or two may often pass without any extension, while 
at the end of that time a fresh start is taken, and two or more of these 
stationary periods are not uncommon in the course of the malady. The 
ordinary tendency of the affection is however progressive; and although, 
as I have said, the disease may pursue the most eccentric course, attack- 
ing groups of muscles here and there, it will involve ultimately a very 
great number, and finally those supplied by the lower cranial nerves, un- 
less it be checked by proper treatment. 

I may illustrate the symptomatology of progressive muscular atrophy 
by a case which ran a somewhat irregular course by attacking the muscles 
of the lower extremities : — 

J. F. H., 31 years old ; U. S. ; engineer. Twenty-one months ago the 
patient, after exposure, developed what he says was articular rheumatism, 
which chiefly affected the legs. On recovery he noticed that the right 
leg " began to grow smaller at the calf," and that afterwards his left 
thigh became smaller. His pains continued at intervals, and were in- 
creased by damp weather. 

Present Condition. — The muscles of the anterior part of legs and thighs 



298 



DISEASES OF THE SPINAL CORD. 



are mucli wasted, the abductors of thighs and the recti femoris on both 
sides being notably so. The knees seem very large, and the condyles of 
the femur are felt to be superficial and covered tightly by the skin. There 
is no loss of sensation, and electric irritibility appears to be very generally 
preserved, except in the recti femoris. The glutei muscles have suffered 
to some extent on both sides. He has severe pain at night, which runs 
down the legs, and " seems to be deep." There is impaired motor power, 
and he finds that walking is diflicult. He does not experience ^ny urinary 
trouble, and his bowels are not constipated. There is no loss of co-ordi- 
nating power, no constricting band, no history of any kind of acute mye- 
litis. The muscles on the outer side of the thigh are the seat of fibrillary 
contractions, which occur sometimes when he makes a voluntary effort. 
There was at this time no atrophy of any of the muscles of the upper 
extremities, but when I saw him some months subsequently there was 
commencing atrophy of the muscles of the right hand. In the paralyzed 

Fig. 45. 




Atrophy of the Left Shoulder. 

muscles the temperature is much lowered, and this is a constant feature of 
the disease. 

Jaccoud^ and others have called attention to a temperature change, 
which they call " refroidissement variable," in which there are times 
when the temperature may fall several degrees, and this seems to be 
the result of a paroxysmal ischsemia of the tissues. The pupillary con- 
dition is an interesting feature of the disease, the dilators sometimes being 
paralyzed, so that the pupils are widely or unequally dilated. 



] Op. eit., p. 326. 



PROGRESSIVE MUSCULAR ATROPHY. 299 

It is the rule, in these cases, to discover certain trophic changes affect- 
ing the skin and its appendages, so we quite commonly find diseases of the 
nails, eruptions, and other cutaneous lesions ; but a patient now under 
treatment presents something in addition to these. It has been found that 
he sweats profusely upon the right side of the body, which is more atro- 
phied than the left, while the left side is quite dry. 

By careful experimentation I have found that when ammonia is held 
to his nose the right eye almost immediately becomes suffused with tears, 
while the left remains almost entirely unaffected. 

When salt is placed upon the tip of the tongue an abundant discharge 
of saliva from the right corner of the mouth occurs almost at once. 

Dr. Claddek, my assistant at the Hospital, painted with cantharidal 
collodion two spots of the same size upon either side of the chest, and 
upon the normal side only very slight changes took place, while upon 
the right, or affected side, a blister was formed almost immediately, and 
it was very slow in healing. 

In many cases the general health of the patient is unaffected in any 
way, and yet the atrophy may be of the most complete nature. I recently 
saw a patient thirty-eight years old, who had been a soldier in the regular 
army, and was exposed much to the elements. His illness has lasted but 
two years, yet in that short time nearly every voluntary muscle has under- 
gone a great diminution in size, except those of the face. His respiration 
is labored, and he cannot stand without support. He is 5 ft. 8 in. in 
height, and his anterior dorsal curve is four inches in extent. In a line 
measured at level of nipples his chest girth is 26 inches ; at inspiration 
there is a gain of two inches. The right arm at middle of biceps is 61 
inches in diameter ; the left 6i inches. All the bony prominences are 
distinct, the angles of the scapulae approximate, and he is almost a skele- 
ton in appearance. There is no loss of sensation : 

The atrophy in this case was as great as that presented by Duchenne's 
patient,^ Bonnard, in which the pectoral, trapezii, with the exception of 
their clavicular portion, great muscles of the back, biceps and anterior 
muscles of the left arm, supinatores longii, had nearly entirely disap- 
peared. 

Duchenne alludes to the changes in conformation of the thorax when 
the intercostals or diaphragm are paralyzed, and presents two illustrations 
showing the perimeter of the chest in two patients affected with atrophy. 
These are presented in the accompanying illustrations. Thoracic troubles, 
such as bronchitis, are not uncommon as a result of impaired lung action. 

Causes. — These may be enumerated as heredity, which is found to 
enter conspicuously into the etiology of progressive muscular atrophy, 
exposure, the over-use of particular groups of muscles, injury of the spinal 
cord, and sometimes syphilis and the zymotic diseases. As to the heredi- 
tary influence which favors its development, Friedreich^ reports several 
cases, which go to show that this disease, more than all others, commonly 

1 Op, cit., 3rd ed., p. 500. 2 Qp. cit. 



300 DISEASES OF THE SPINAL CORD. 

Fig. 44. 





(Duehenne.) 

appears in several generations of the same family. I have seen one case 
where it could be traced for three generations back, and in another, which 
I will presently detail, there were uncles and aunts affected. Eichert,^ 
in a very valuable article, gives the family history of one case. In a 
genealogical table he traced the disease back six generations, and repre- 
sentatives of these generations are still living. Seven cases are related 
by him. In two of the cases the parents have escaped, while the children 
have suffered. It is unnecessary to pursue this matter further ; but I am 
firmly convinced that there is no other disease, except perhaps it may be 
phthisis pulmonalis, which is transmitted so frequently as this terrible 
malady. Exposure to damp, neglect to change wet clothing, and like 
imprudences, are exciting causes in many cases. Neuralgic pains are 
very prominent in such cases, and the onset of the disease is rather pre- 
cipitate. Mechanics of all kinds, who are in the habit of using some 
muscles much more than others, are frequently the victims of the disease, 
and the muscles which have been over-used are affected before the others. 
I have seen the same limited atrophy in a cigar-maker and in a composi- 
tor, who used certain groups of muscles almost constantly. Roberts has 
dwelt upon the connection between injury of the spinal cord and the dis- 
ease under consideration ; and Valentiner,^ Bergmann,^ and Thudicum 
have all called attention to the appearance of the disease some time after 
the receipt of an injury. Roberts reports a case in which atrophy of the 
ball of the right thumb, and subsequent complication of the respiratory 
muscles, and death followed a slight injury received six months before. 
The other cases are none the less interesting, and go to prove the import- 
ance of recognizing such causes. As to age and sex, it has been found 
that progressive muscular atrophy is not confined to any period of life, 
but the bulk of cases occur after puberty. Of 88 cases reported by 
Roberts, 1 was only 2 years old, and another 69. Of the 28 cases I have 
seen, the atrophy began in 2 between the 5th and 10th years; in 5, 
between the 10th and 15th; in 18, between the 20th and the 30th; and 
in 3 after the 30th. Of these, 23 were men, and but 5 women. This 

1 Prag. Viert., 1855. ^ Berliner Klin. Wochenschrift, Oct. 20, 1874. 

3 Petersburg Med. Zeitsch., 1864. 



PROGKESSIVE MUSCULAR ATROPHY. 301 

seems to be the rule, and Koberts states that six men are affected to every 
woman, and he considers this due to the exposure and external violence 
to which males are subjected. 

Morbid Anatomy and Pathology. — The disputed point in regard 
to the pathology seems to be whether it is a primary peripheral condition, 
or whether it is a central affection in which the trophic cells are affected. 
The advocates of the first theory call attention to the fact that muscular 
atrophy occurs independent of any loss of the muscular function, and 
believe it to be purely a local degeneration. The authorities I have 
spoken of, in alluding to the early history of the disease, all believed in 
this intra-muscular origin ; but lately there have been so many proofs of 
its central origin brought forward, that the former theory has been aban- 
doned. This difference of opinion seems to exist in regard to the form of 
central lesion. The majority of observers are agreed that there is an 
affection of the anterior horns ; and that the change is one that affects 
the trophic cells of Duchenne and Westphal, and the fibres which con- 
nect with sympathetic ganglia. 

To Lockhart Clarke,^ who has so often decided questions regarding the 
pathology of nervous disease, belongs the credit of having discovered the 
central origin of this disease. He found atrophy of the anterior gray 
horns, and since his original observations many other observers have 
come forward to endorse his views. Von Recklinghausen and DumeniP 
disagree, however, with this view, and the microscopical examination 
made by the former was unattended with any discovery of morbid appear- 
ances. 

Jaccoud has collected six cases in which fatty degeneration of the 
sympathetic had taken place, and one of them was observed by this author 
himself Not only was there fibro-fatty degeneration of the sympathetic 
nerve, but there was atrophy of the anterior roots. The view held by 
Jaccoud is that the trophic filaments of the sympathetic which preside 
over nutrition do not perform their duty, and that the affection of a 
mixed nerve, which contains motor, sensor, and trophic filaments, at a 
point where they are intimately mixed, must result in a perversion of all 
their functions ; but if the separate filaments be attacked at a point be- 
fore they become blended, there may be independent loss of function of 
either one.^ 

Charcot and Gombault* have described the following interesting post- 
mortem appearances witnessed in a recent case : — 



1 Brit, and For. Med.-Chir. Keview, vol. xxx., 1862. ^ (j^z. Hebdom., 1867. 

^ The localization of well-defined lesions in this disease is sometimes made before 
death and verified afterwards. Prevost and Cotard (Archives de Physiol., Sept., 
1874) present such a case. There was atrophy of the right thenar eminence, with 
atrophy of the right anterior root of the eighth pair of cervical nerves, slightly 
marked atrophy' of the right anterior root of the seventh cervical nerves, and atrophy 
of the gray matter of the anterior horn at this level of about an inch in extent. 

* Archives de Physiol., 1875, No. 5, abst. Phil. Med. Times. 



302 DISEASES OF THE SPINAL CORD. 

"No change in hemisphere, cerebellum, pons, or medulla oblongata in 
these nerves. The gray substance of the cervical and dorsal medulla 
spinalis was greatly altered from the lower portion of the cervical enlarge- 
ment down, gradually decreasing downwards and outwards. The nerve- 
cells Hnd nerve-fibres of the anterior gray cornua had disappeared; the 
capillary vessels were greatly developed ; the parietes of the smaller and 
larger vessels were thickened. The lumbar portion of the cord and the 
lateral columns were normal. In the cervical and dorsal region, the 
portions of the cord near the merging external roots were sclerosed ; the 
change being proportionate to the intensity of that which had taken 
place in the gray cornua. The few ganglion-cells present were very 
much diminished in size, without processes, more rich in pigment than 
normal, but still containing nuclei and nucleoli. The anterior roots of 
the cervical region were atrophic ; empty sheaths, frequently containing 
large nuclei, appeared in place of the normal fibrillar contents. The 
posterior roots seemed normal. 

" As to the peripheral nerves, one phrenic and several intercostal 
nerves were examined ; more than two-thirds of the nerve-tubules (in 
hardened sections) were wanting, by a process similar, as it would ap- 
pear, to that induced by an external wound. The muscles about the 
shoulder and the upper extremities were for the most part atrophic ; 
there seemed to be a peculiar atrophy of the primitive fasciculi, without 
any marked alteration in the fibrils, and without any excessive develop- 
ment of the interfibrillar fatty tissue." 

The changes discovered by Clarke^ were in the gray matter. There 
was a granular deposit about the vessels, and corpora amylacea about the 
central canal. Lesions of the anterior nerve-roots were found, and in the 
cervical region there seemed to be more distinct appearances than at any 
other point, where it will be remembered there may be found sympathetic 
as well as motor and sensor fibres. 

The muscles present distinct evidences of fatty degeneration and fatty 
substitution. They appear to the naked eye as wasted bands which con- 
tain lines of fat. The appearance of healthy muscles of good contour in 
juxtaposition with others which have undergone atrophy is very peculiar, 
and it is difficult to realize that the disease can involve such isolated 
tracts. The muscles of the lower extremities may have undergone general 
fatty degeneration. A specimen prepared by my friend Dr. Weisse, of the 
Medical department of the N. Y. University, shows very beautifully this 
condition of affairs. Fatty substitution has gone on to such an extent 
that there is no appearance of muscular fibre to be seen, but every muscle 
exists as a distinct band of adipose tissue. Atrophied muscles have been 
examined by Meryon,^ Galliet,^ and others, and their descriptions of ap- 
pearances agree very closely. The muscular structure suffers a complete 
change, the striae disappearing and the sarcolemma undergoing a granular 
change. Fox* divides the secondary changes into the fatty degeneration 

1 Med. Chir. Trans., 1851, 1856. 

2 Ibid., 1866. 

^ Archives Gen., vol. i., 5me s^rie, 1853, p. 584, 
* Op. cit., p. 266, et seq. 



PROGRESSIVE MUSCULAR ATROPHY. 303 

which takes place inside of the sarcolemma, and as an interstitial deposit. 
These he calls the parenchymatous and the interstitial. Sometimes, as 
observed by Robin, the atrophy may take place as a fibrous degeneration, 
or species of muscular sclerosis. Some muscles appear as fibrous cords of 
a white color, while others may be found which have undergone the faity 
degeneration just described. 

An instructive case in which very striking appearances were presented 
was observed by Dr. Janeway, whose observations are recorded below : — 

M. G., aged 62 years, widow ; admitted to hospital December 16th, 
1873. Right hand : the muscles of ball of thumb are very much atro- 
phied, and she is unable to move it ; there is also slight rigidity of the 
joints of the thumb. 

Dorsal interossei are very much wasted ; there is slight power of flexion 
and extension of fingers, especially little fingers, and there is also a slight 
movement at the wrist. 

Sensibility good except in index finger, and here it is decidedly dimin- 
ished. She can raise her arm to her head and place it in any position. 
Hands seem cold. 

Left hand is not so much afiected ; the muscles of ball of thumb are 
partially wasted. The abductor opponens and outer head of flexor brevis 
are almost gone ; the inner head of flexor brevis and abductor partially, 
and capable of acting to a slight extent. Has slight power of ab- and ad- 
duction of fingers, especially the little finger, most on the ulnar side, and 
decreasing toward the radial ; has slight power of extension over fingers, 
none over thumb, but flexion power is more marked. Has no power of 
extension, but considerable of flexion at the wrist. 

Dynamometer L. H. 28. Sensibility normal ; hands cold. The mus- 
cles that are capable of acting respond to the induced current very well. 

July 9. Complains of dizziness and nausea 

17th. Dizziness still. Her hands are in same condition. She expe- 
riences some difficulty in walking, and moves with her body '' sloping 
over " She cannot use her hands, and when she attempts to do any- 
thing, they drop, and she cannot raise them. The muscles that remain 
unaffected respond well to electricity. She still vomits at times after 
eating. 

August 3 Is quite weak ; has chilly sensations. 

4:th. Had a severe fever last night ; temperature 104° ; passed feces 
in bed, and did not know it; to-day temperature is almost normal ; is quite 
apathetic. 

dth. Has chilly sensations ; complains of no pain ; arms and jaws trem- 
ble ; temp. 102°. 

2 P. M. Temp. 102°. 

Qth. She is very much worse ; mucous rales heard all over chest ; respi- 
ration accelerated ; temp, high ; pulse very feeble ; pupils normal ; bowels 
moved once to-day ; swallows with great difficulty. 

2. P. M. She sank gradually and died at 12.45 P. M. 

Post-mortem, held twenty-seven hours after death. — Rigor mortis mode- 
rately well marked. Nearly all the muscles of the hands are atrophied, 
especially the dorsal interossei and the propria muscles of the thumb ; the 
change is nearly symmetrical in both hands. The forearms are extremely 
wasted, both on the flexor and extensor surfaces. There is no marked 



304 DISEASES OF THE SPINAL CORD. 

wasting in the arms, the shoulders are well rounded ; both pectoral regions 
appear wasted ; there is no marked wasting in the lower extremities, un- 
less it be in the adductor region of both thighs. Incisions made into the 
pectoral muscles, show well-colored fibres also in the deltoid, biceps, and 
triceps. 

The extensors of the forearms are of whitish-yellow color, being nearly 
as pale as the skin. 

The flexors of right hand are very much wasted, but not so much as 
the extensors. The flexors of the left side are small, but seem in good 
condition. 

The muscles of the right thenar eminence show extreme degeneration. 
In left thenar eminence the inner head of flexor brevis and adductor are 
red and large ; the external is white, as on the other side. The adductors 
of thighs are small, but well-colored. 

The quadriceps extensor femoris is of good color. 

The anterior tibial muscles are of good color. 

Heart : Valves are normal, muscular substance soft, and yellowish- 
gray. The diaphragm is not atrophied. 

Brain : Convolutions and corpora striata appear normal. There is 
some atheroma of the carotid and basilar arteries. 

The substance of the cord and brain is quite soft. The viscera are nor- 
mal, except the kidneys, and these are granular; their pyramids are 
small, and they contain small cysts. 

Diagnosis. — Progressive muscular atrophy may be mistaken for seve- 
ral conditions of a paralytic nature, among these lead paralysis, antero-la- 
teral sclerosis, partial paralysis from traumatism, and infantile or adult 
paralysis. 

For an illustration of the first of these I do not think I can do better 
than mention a case in which there appeared to be lead paralysis, but 
which subsequently turned out to be progressive muscular atrophy. 

Several months ago, Mr. N"., a Cuban gentleman, came to me with a 
letter from his medical adviser. Dr. Findlay, of Havana. The doctor's 
history of the patient is as follows : " Mr. N., about eighteen months 
ago, began to experience a tremor in the fingers and wrist of the right 
hand, together with muscular debility, which caused some inconvenience 
in writing, and in carrying food to his mouth, as well as in other move- 
ments of the hand. Having on a single occasion submitted to local fara- 
dization of the arm (some ten montlis ago), the tremor was much sub- 
dued, and, as was thought, the fingers and wrist were strengthened. It 
was not, however, until four months ago that the patient returned to put 
himself under a regular course of treatment. 

" Condition of the patient in July, 1876. — General health good ; no 
signs of cachexia ; no antecedents of specific taint ; no lead poisoning. 
SuflPered on two or three occasions, at some years' interval, rheumatic 
pains and neuralgia in the arm and shoulder of the left side, but never in 
the right side, which is the one now aflfected. The outer appearance of 
the right arm showed but little muscular atrophy ; the tremor was incon- 
siderable ; the patient could close the hand tightly, but not well grasp 
larger objects, such as a tumbler, owing to incapacity to maintain tha first 



PROGRESSIVE MUSCULAR ATROPHY. 305 

phalanx of the third, fourth, and fifth fingers extended. The wrist was 
inclined to drop forwards (in flexion) and outwards. 

"On inspection it was found that the common extensor of the fingers 
was considerably weakened, most so in the portion attached to the ring- 
finger, the weakness being manifested both to voluntary and to electrical 
contractility. The same condition existed also, though a little less, in the 
extensor of the little finger, and in the radial extensors. The contractil- 
ity was not totally absent, but would vary in degree without apparent 
cause. The disease continued to progress (notwithstanding treatment), the 
portions of the common extensors losing all excitability to my small 
Gaiffe's battery, and the extensors of the thumb being also implicated. 

" The left arm was now examined, and although the patient did not 
notice any weakness in the hand, yet some deficiency of electric contrac- 
tility was observed in the common extensor, especially in the extensor 
of the ring-finger. The constant current was now used for six weeks 
without much benefit. The extensor carpi ulnaris is now becoming also 
afiected. The patient, however, finds that he can write and perform 
various acts with the right hand better than before. Within the last 
week he complains of some pain along the back of the left forearm when 
he has been holding an object in the air, and feels an inclination to relax 
his grasp." 

The doctor also gave a history of hereditary trouble, which was proba- 
bly in one case (the patient's uncle) progressive muscular atrophy. 

I carefLilly examined the patient, and found that the right arm was 
that most afiected. 

Motor 2^owe7\ — The power of extension of the muscles of the right 
forearm was lost completely, and on the left side the power of exten- 
sion of the two middle fingers was to some degree impaired. Flexion 
was perfect. 

Atrophy. — The following muscles were more or less affected and re- 
duced in size. Right forearm : Extensor communis digitorum ; extensor 
minimi digiti ; extensor carpi radialis ; extensor longis pollicis ; extensor 
carpi ulnaris ; extensor communis of the left. 

Sensation. — Slightly impaired on the right side. The teeth of the 
sesthesiometer were separated by a space of about ten centimetres before 
two points could be appreciated. This loss was not so great on the under 
surface of the forearm. There was no history of recent pain either con- 
stant or neuralgic, nor were there any dyssesthetic sensations. 

No fibrillary contractions were observed. There was a slight tremor 
in the right hand when voluntary movements were made. Electric con- 
tractility to a very slight degree was observed in the extensor communis 
digitorum when a strong faradic current was applied. The galvanic cur- 
rent also seemed to have some influence upon the weakened muscles. The 
fingers were covered by small flakes of skin, and the nails were crenated, 
irregular, and evidently badly nourished. This trophic defect disappeared 
under the use of the galvanic current. 

Diagnosis — In the order I name them I proceeded to dispose of lead 
paresis, amyotrophic sclerosis, cerebral paralysis, traumatic paralysis, and 
progressive muscular atrophy. 

That it might be lead paresis seemed reasonable at first, because of the 
loss of electric contractility, the seat of the paralysis, etc. ; but when I bore 
in mind that the trouble was one-sided at first, that there was a subse- 
quent invasion of the muscles of the other arm, that sensibility was also 
20 



306 DISEASES OF THE SPINAL CORD. 

impaired, and that the patient used neither hair-dye nor drank impure 
water, nor was exposed to the dangers of lead poisoning of any kind, I 
was forced to abandon this idea. A species of spastic contraction drew 
down the fingers of the right hand and there was some cumulative tre- 
mor, such as characterizes sclerosis (expressed by a gradually increased 
tremor, aggravated by will control, and terminating in a species of 
spasm). This at first led me to suppose that there might be some degene- 
ration of the lateral columns, but as the tremor disappeared and there 
were no other symptoms of such degeneration, and especially as there was 
gradual atrophy and muscular paralysis, I dismissed this possibility. The 
loss of electric contractility, and the limited field of the paralysis, ex- 
cluded cerebral paralysis ; and the fact that the patient had never received 
an injury, and that the affection was beginning to affect the opposite 
group, negatived the theory of traumatic paralysis. All that was left 
was the diagnosis of progressive muscular atrophy ; and the subsequent 
appearance of fibrillary contractions made me quite sure of my decision. 
The slow progress of the trouble and its site were, however, doubtful 
points. The individual had not exercised any particular member, and 
as he was a man of leisure, there was no trade or occupation in which 
constant use of the hands or excessive labor was required that could ac- 
count for its origin. The hands preserved their contour ; there was no 
atrophy ; no prominent thenar eminences ; nothing suggestive of the 
main en griffe. None of the muscles of the back were affected, and the 
deltoids were of good volume and power. The fact that others in his 
family had suffered, that the disease began on one side and extended to 
the other, that fibrillary contractions were present, that subsequently I 
was enabled to get slight, and afterwards stronger contractions of the 
paralyzed and atrophied muscles, determined me in my diaguosis of this 
anomalous case. I call it anomalous, because I have been taught, and 
my own experience convinces me, that this is a very rare seat of pro- 
gressive muscular atrophy. Protean as is the malady, I have not seen 
paralysis of the extensors, as a primary symptom, in any one of the 
twenty eight cases of the affection I have met with from time to time. 

In lead paresis the invasion is rapid, the paralysis the same, and the 
atrophy is secondary, which is not the case in the wasting palsy. There 
is sometimes the lead line or lead colic, and electric contractility is im- 
paired from the first. From traumatic paralysis it can be diagnosed by 
the irregularity in situation of the muscles atrophied. In traumatic 
paralysis we may look for atrophy of groups of muscles which are sup- 
ported by a common trunk, as well as loss of electric contractility and 
secondary atrophy. 

The diagnosis from some forms of adult and infantile paralysis is not 
so easy. In fact Duchenne believed the pathology of the two affections 
to be nearly the same. The sudden origin of the infantile cases of course 
precludes any mistake in the majority of cases, but in adult cases even 
after the disease has existed for some time. 

In such cases the paralysis and atrophy may co-exist to a dispropor- 
tionate degree. If it is possible, however, to ascertain the early occur- 
rence of paralysis, and if the loss of muscular substance be rather general, 
no mistake need be made. 



PROGRESSIVE MUSCULAR ATROPHY. 307 

Prognosis. — Occasionally the malady may be arrested or cured en- 
tirely, and this fact seems almost incredible when we bear in mind its 
organic character. The duration of the disease is variable. Some of 
these patients recover, while in other cases it runs its course in from five to 
twenty years, the atrophy meanwhile involving fresh groups of muscles 
with more or less rapidity. 

In a case shown at my clinic, the disease had lasted for two years, and 
the atrophy had involved nearly all the muscles of the upper part of the 
body. In another patient I have recently seen, the disease has progressed 
very little during the last ten or twelve years. 

I have succeeded in arresting the disease in ten cases, and think that, 
when there is the least muscular response to electricity, there is still a 
chance for improvement, if not complete relief. This is, of course, in 
proportion to the extent of invasion. If the atrophy be confined to the 
muscles of one forearm, there need be no reason to give a bad prognosis. 
The majority of cases, however, go on to an unfavorable termination, 
and perhaps one reason is, that patients delay so long to seek medical 
advice, considering their disease to be rheumatism, and amenable to do- 
mestic treatment. When the diaphragm or the intercostales are invaded, 
the prognosis is as bad as it well can be. 

Roberts ^ thinks that the prognosis is bad when hereditary predisposi- 
tion can be traced, or when the upper and lower extremities are both 
implicated. 

Treatment. — I know of no other remedies than those which are local 
(except when a syphilitic taint is suspected). Electricity is one of these ; 
muscular rest is the second when the affection has followed over-use of 
certain muscles. 

The galvanic current from not less than twenty cells should be used, 
one electrode being placed over the nucha, and the other in the supra- 
clavicular space. Applications of ten minutes every day cannot fail to do 
good. In addition to this, the faradic current should be employed for 
the muscles themselves, making each muscle contract several times, and 
then allowing it to rest, and repeating the operation some minutes after- 
wards. Violent electrization, I am convinced, fatigues these crippled 
muscles, and does more harm than good. 

Duchenne gives the following directions for the use of the induction 
current : " Place the wet electrodes, so that they are as near together as 
possible upon the surface of each of the diseased muscles, using an induc- 
tion current of greater or less tension, so that all the anatomical elements 
of the muscle shall be excited. Excite the muscles generally and mode- 
rately and apply an intermitted current. Faradize only the atrophied 
muscles which still respond to electric excitation, among the latter, fara- 
dize by preference those which enter most frequently and usefully into 
important muscular movements. Eud each seance by the slow faradiza- 

^ Art. Wasting Palsy, Eeynolds's System of Medicine, American Edition, vol. i., 
p. 796. 



308 DISEASES OF THE SPINAL CORD. 

tion of the more important muscles among those threatened by the inva- 
sion of atrophy." 

Vivian-Poore and Fagge ^ have had wonderful success with this agent, 
and have cured a number of apparently hopeless cases. I have been 
induced to try the " rubber muscle," as arranged for lead paresis. This 
forms an admirable means for support of the hands, should the extensors 
be affected, as was the case in the history I have just related, In every 
case it is well to insure perfect rest, if possible, for all affected muscles. 
If the muscles of the shoulder be so atrophied as to allow the arm to 
drop, it is well to arrange some contrivance to sustain its weight, and 
relieve the strain upon the affected organs. Sulphur baths and mineral 
waters have been recommended, and in some hands have been successful. 

PARTIAL FACIAL ATROPHY. 

Synonyms. — Trophic neurosis of the face (Romberg) ; Laminar 
aplasia (Lande) ; Unilateral progressive atrophy of the face (Eulenburg^). 

Definition. — A disease of a trophic nature, involving usually one 
side of the face, beginning with discoloration and cutaneous changes, and 
ending in loss of tissue of underlying cellular tissue and bone, not accom- 
panied by loss of motor power or sensibility. 

The disease was, according to Eulenburg, first described by Parry ^ in 
1825, and afterwards described by Bergson* in 1837. 

It subsequently received attention from Romberg,^ Lande,^ Samuel,^ 
Eulenburg,^ Fremy,^ Moore ^° and others, who described many cases. 
Eleven cases are reported by Lande alone. The first American case was 
presented by Dr. Draper " before the New York Society of Neurology, 
Dec. 20, 1875, and other cases have been brought forward since by Se- 
guin, Robinson, Bannister and others.^^ 

A photograph of Dr. Draper's case is presented below. 

The patient, who was a stout, hearty Irish girl, aged 18, and without 
any hereditary predisposition, presented herself, with the following his- 
tory : About two years ago the muscles under the body of the lower jaw 
of the left side began to diminish in size, and after a few months there 

I London Practitioner, December, 1868. 
2^Ziemssen's Cyclopaedia, p. 57, vol. xiv. 
3 Quoted in Eulenburg' s article. 

* De prosopodysmorphia sive nova atrophise facialis specie, Berlin, 1837. 
5 Klinische Ergebnisse, 1846, and Klinische Wahremung, etc., 1851. 
® Essai sur I'aplasie lamineuse de la face en particulier these de Paris, 1869- 
■^ Die trophischen Nerven, Leipzig, I860. 

8 Wiener Med. Woch. und Lehrbuch der functionellen Nervenkrankheiten, 1871. 

9 Etude critique de la trophonevrose, Paris, 1873. 

10 Dublin Quarterly Journal, 1862. 

II Am. Psychological Journal, Feb., 1876. Also consult recent cases in Bull, de la 
Soc. de Chirurgie, vol. 2, 1876. Gaz. Hebdomidaire, No. 13, p. 196, 1876. Br. 
Med. Journal, Aug., 1876. 

^2 Journal of Nervous and Mental Diseases, 1876, vol. i. 



PARTIAL FACIAL ATROPHY. 309 

was gradual extension of the atrophy, so that finally a district bounded 
by the symphisis of the lower jaw, angle of the nose, and middle of the 
upper lip in front, lower edge of zygoma above, and ramus of the inferior 
maxillary behind, became entirely afiected. The skin is bound down to 
the periosteum of the lower jaw, and is shiny, tense and white. There 
never has been pain of any kind, but the only sensory alteration occurred 
in the beginning, when a slight itching was felt. There is no ansesthesia 
anywhere, not even in the tongue, one side of which is markedly atro- 
phied. In the beginning there were occasional cramp-like pains about 
the insertion of the masseter muscles on the left side, but none on the other. 
There was slight paresis in some of the muscles involved. 

Fig. 46. 




Partial Facial Atrophy. 

In twelve Continental cases collected by Draper, eight of whom were 
women and four men, the atrophy appeared in one at three years of age, 
and in another at twenty-two years of age. The beginning of the atrophy 
in these cases was not always the same. In two instances it began by 
pallor ; in the others by red spots, next followed by loss of color ; and 
finally there was a parchment-like appearance of the skin. Sensibility 
was not lowered in any instance, but in two there was itching, as in Dra- 
per's case. In one the disease was preceded by spasms of the masseter 
muscles ; in six the tongue was atrophied ; in one the tonsil ; and in the 
rest the soft palate. In two cases there was deafness. In no case was 
there affection of the secretion of saliva ; but in one there was diminished 
pulsation in the carotid of the affected side. In none were there indica- 
tions of central disease. The cutaneous changes alluded to are peculiar, 
and a variety of trophic alterations may attend the disease ; such, for in- 
stance, as falling out of the hair, or changes in color and the appearance 
of eczema. The sweat-glands do not seem to be involved, but the seba- 
ceous secretion disappears upon the affected side. The atrophy is some- 
times quite extensive, involving the bones, which, in some cases, have 



310 DISEASES OF THE SPINAL COED. 

been measured and found to be greatly reduced in size. Electric contrac- 
tility of the muscles does not appear to be in the least diminished. The 
temperature of the affected side is generally lowered, but there is no di- 
minution of sensibility. The left side appears to be the more common seat 
of the disease, and of the twelve cases already alluded to, but one was of 
the right half of the face. 

Causes. — In some of the reported cases there was a history of pre- 
vious intermittent fever, scarlatina (Hueter refers to whooping-cough as 
having had something to do with the genesis of this disease), and scrofula, 
and in one case there was a fall upon the head, but it is a question of 
great doubt whether these were concerned in the development of the atro- 
phic condition. Courtet reports a case of right-sided facial atrophy in a 
subject who had been delivered with forceps. In this case the right pupil 
was the largest, which suggests the fact that there may have been some 
intracranial lesion. It seems, however, to be a disease which is more 
common between the tenth and the thirtieth year, and women are more 
often affected than men. 

Pathology. — Undoubtedly this disorder is one of a trophic nature, 
and of central origin. The absence of motorial or sensorial disturbances 
makes this theory very plausible. If the lesion were of a peripheral char- 
acter, it is highly probable that both sensation and motion would be af- 
fected, for I cannot conceive a diseased condition of trophic filaments 
alone when they are found in company with other sensor and motor fila- 
ments, as in a nerve-trunk which is diseased. This hypothesis seems more 
reasonable when it is borne in mind that the parts atrophied are supplied 
by other cranial nerves than the seventh. I therefore think that the the- 
ory of degeneration of the trophic cells of the bulb is a much more ac- 
ceptable one than that held by Bergson and others. Eulenburg considers 
it to be essentially a lesion of the fifth pair, in which opinion he is sus- 
tained by Romberg, Samuels, Charcot, and Vulpian. Against this it 
may be urged that lesions of the fifth nerve of a trophic nature are gene- 
rally followed by corneal changes, which, so far as I can learn, have never 
been witnessed in this disorder. Brunner is of the opinion that the con- 
dition is connected with a continued irritation of the cervical sympathetic 
upon the affected side. 

Diagnosis. — Progressive muscular atrophy and facial paralysis seem 
to be the only diseases with which this may be confounded. Against 
the first it may be said that there are never the peculiar cutaneous 
changes of the disease under discussion — no dark spots, no falling out of 
the hair, no tightness of the skin ; and moreover, this site of atrophy is 
very rare in progressive muscular atrophy. Facial paralysis is nearly 
always of sudden appearance, and the muscles lose their electric con- 
tractility. 

Prognosis. — As far as I can learn no deaths have been reported, and 
no cures by drugs. From its progressive nature (and particularly if we 
concede it to be a central disease of a degenerative character) the prog- 
nosis must be bad, though two or three cases have been related, however, 



PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. 311 

in which there was an arrest of the atrophy without any treatment. In 
Belot's^ case the disease became stationary after a year. 

Treatment. — Electricity is indicated, but its use has only once been 
attended by slight improvement in the hands of Moore/ who reported a 
case which was benefited. 

PSEUDOHYPERTROPHIC MUSCULAR PARALYSIS. 

Synonyms. — Myosclerotic paralysis ; sclerose musculaire progressive 
(Requin) ; myosclerosis. Lipomatosis musculorum luxurians (Heller). 

Definition. — A disease of infancy, expressed by increase of volume 
and hardness of certain muscles usually of the lower extremities, such in- 
crease being due to fatty substitution ; by secondary atrophy and paresis 
and by conservation of cutaneous sensibility and the functions of the bow- 
els and bladder. 

Though first described by Sir Chas. Bell'' in 1830, by two Italians, Coste * 
and Gioja in 1838, and subsequently by Meryon** in 1852, it was not un- 
til 1868 that the disease received much attention, when Duchenne^ 
presented his collection of thirteen cases, with a critical analysis. At 
about the same time Meredith Clymer^ was the first in this country to 
describe the condition. After him, Ingall and Webber,*^ Pepper,** Weir 
Mitchell,^" and others, and among them Poore,^^ of New York, has fully 
discussed the subject, while numerous continental writers have published 
cases. 

Of late, Gowers^'' has embodied his carefully made and valuable ob- 
servations in a well written volume in which the history of the disease is 
illustrated by brief reference to the cases reported by Continental, Eng- 
lish and American authorities, one hundred and seventy-six in number. 
Of these, all but eight were among children. 

Symptoms — Duchenne details the symptoms in the following order : 
1. In the beginning, feebleness of the lower limbs. 2. Lateral balancing 
of the trunk and widening of the legs during walking. 3. A peculiar 
curvature of the spine or saddle-back, both in walking and standing. 
4. Talipes equinus, with an over extension of the first phalanges of the 
toes. 5. Apparent muscular hypertrophy. 6. Stationary condition. 
7. Generalization and aggravation of the paralysis. These are the strik- 
ing features of the disease, which is far from common, — and, so far I 

^ Quoted by Draper, Am. Psy. Journal, Feb., 1876. ^ Op. cit. 

3 Nervous System of the Human Body, etc., 2d Ed., 1830, 3d Ed., 1836. 
* Referred to in Schmidt's Jahrbuch, xxiv., p. 176 and by Gowers. 

5 Transaction of Medico Chirurgical Soc, xxxv., 1852. 

6 Archives General de Med., January, 1868, and following numbers. 

7 Appendix to Aitkin's Practice of Medicine, 1868. 

8 Boston Medical and Surgical Journal, Nov., 1878. 

^ Philadelphia Medical Times, June and July, 1871. 

10 Photographic Review, Oct., 1871. 

11 New York Medical Journal, June, 1875. 

12 Pseudo-Hypertrophic Muscular Paralysis, a clinical lecture, London, 1879. 



312 DISEASES OF THE SPINAL CORD. 

have seen less than a dozen cases. In illustration of the development 
of the disease, I may present the history of a well-marked case which I 
was permitted to examine by Dr. V. P. Gibney. 

F. S. M., aged 13. Previous health excellent, her only illnesses being 
whooping-cough at the age of 9 months, and scarlatina one year ago, 
which was followed by some otitis. Her family history is good, so far as 
nervous disease is concerned. Her father died of phthisis, and her mother 
is alive and healthy. Her ancestors were long-lived people. She tells us 
of an injury received in 1870, a boy having thrown a brick at her, which 
struck her in the small of the back. ISTo fever or pain preceded her 
present trouble. Her disease was of gradual development, and the hyper- 
trophy followed the injury which has just been alluded to. At the end of 
six months she found it difficult to go up stairs, and her helplessness in- 
creased until the time of admission into the Hospital for Ruptured and 
Crippled, April 7, 1876. The following history was then taken: Com- 
plexion, light ; hair, brown ; eyes, hazel. She is small for her age, though 
well developed. She stands with abdomen prominent, chest and head 
thrown backwards ; walks with an unsteady, waddling gait. Upper ex- 
tremities, with exception of elbow-joints, which permit extension beyond 
an angle of 180^, normal. From the sixth dorsal to the sacrum there is 
a lordosis of three inches, the point of greatest incurvation being at the 
third lumbar vertebra. There is tenderness on deep pressure over the 
twelfth dorsal vertebra, while both trochanters stand out prominently, and 
the limbs are widely separated, and there seems to be no trouble about the 
hip-joints. There is marked diminution in power of the extensors of the 
legs, preventing her from holding the limb at a right angle to the body. 
There is no marked loss of power in the jSiexors. But there seems to be 
some loss of power in the anterior foot muscles ; no comparative atrophy 
of limbs. The muscles of the back seem small and poorly nourished. 
The girl has difficulty in arising from, or assuming the sitting posture. 
The lordosis can be overcome by the voluntary act of stooping forward. 

Treatment. — Spinal brace and electricity. 

Through the kindness of Dr. Gibney, I was permitted to examine 
the patient, whom I found to be a rather well-nourished girl. I was 
immediately struck by her gait, which was characteristic of pseudo- 
hypertrophic paralysis. The feet were planted widely apart, and when 
propulsion was attempted, the whole pelvis was seemingly twisted, and 
the legs clumsily swung forward. The body swayed from side to side, the 
abdomen was prominent, and the shoulders drawn back, so that the ex- 
treme lordosis described so clearly by Duchenne was very beautifully 
shown. When stripped, this exaggerated curve was found to be very 
great. A plumb line held at the seventh cervical spine fell about four 
inches back of a line drawn across the upper edge of the sacrum. When 
my hand was placed upon her abdomen, and an attempt was made to 
force her to stand erect, the nates were immediately thrown backwards, 
and she would have pitched forward if not supported. When she at- 
tempted to walk, the pelvis seemed to be lifted on the side of the limb 
which was raised, and at the same time the corresponding side of the ab- 
domen became quite flat. Her gait was waddling, and she progressed 
very slowly. There was some spinal tenderness, but no other disturbance 
of sensibility either in the sound or hypertrophied muscles. The latter 
were those of the back of the leg, which were much larger on both sides 



PSEUDO HYPERTiROPHia MUSCULAR PARALYSIS. 313 



than they should have been, and were quite hard and in marked contrast 
to the other muscles of the body, which were flabby and poorly nourished. 
The muscles of both thiojhs at the inner side seemed to be atrophied, as 
were all the muscles of the back ; but the arms were of normal contour, 
and apparently unaffected. There was considerable loss of power in the 
lower extremities, the patient being unable without great effort to rise 
from her chair, and when she attempted to do so, she planted her feet 
widely apart and approximated her knees. The color of the skin was 
rather darker than it should be, and especially on the feet, legs, and hy- 
pertrophied calves, was there mottling and imperfect incubation. No 
difference in tactile sensibility could be, noted. Measurements of different 
parts gave the following results : — 

About shoulders 29 inches. 

. About waist 24 " 

Middle of right thigh 14 " 

Middle of left thigh 13^ *' 

Eight thigh, just above knee 11 " 

Left thigh, just above knee 12 " 

Eight calf 12 " 

Left calf 12 " 

A case reported to me by my friend Dr. G. H. Swazey is the following. 
This patient was also seen by Dr. J. Lewis Smith : — 

J. D., aged 2 years 8 months. Has always been a healthy boy until 
four weeks ago, when it was noticed that he seemed weak in his legs, 
especially in the morning, or after sitting awhile. Has not complained 
of any pain. When the child walks, it is in a peculiar wabbling sort of 
a way, with his legs wide apart, and his shoulders carried well back. He 
cannot stand well with his legs close together, but soon totters and falls. 
After he has walked awhile this peculiarity of gait is not so perceptible. 
The left leg measures around the calf eight and one-eighth inches, right 
leg around the calf eight inches. Just above the knee left leg measures 
nine and a quarter inches ; right leg, same place, nine and one-eighth 
inches. 

The weakness in the legs has been steadily increasing from the first. 
The grandmother of the child on the maternal side has epilepsy ; and the 
grandmother on the father's side has what the mother calls weak spells, 
apparently of an epileptic character. An aunt and uncle on the father's 
side have epilepsy, and there is also a history of syphilis in the family. 
The mother has had miscarriages, apparently due to that cause. The father 
has had eruptions and other symptoms. March 28th commenced treat- 
ment with the faradic current to the muscles, which was continued three 
times a week for six weeks ; the disease slowly progressing. At this time 
the patient left off coming, and has not since been seen. 

Weakness of the lower extremities is one of the earliest symptoms, and 
is gradual in its appearance, and not preceded by fever, as is generally 
the case in infantile spinal paralysis. This impairment of power may 
begin imperceptibly, and first attract the attention of the parent by the 
inability of the child to walk at the usual time, or may appear subsequently, 
the child falling frequently or moving clumsily. In Poore's collection of 
85 cases, it is shown that " 3 never walked at all, 24 never walked well, 



314 



DISEASES OF THE SPINAL CORD 



1 is reported as coming on gradually, 52 walked well at first, and in 5 
cases no mention is made of the period of walking." " Of those who walked 
well, 2 began to walk at eighteen months, 3 at two years, 3 at two-and-a- 
half years, 4 at four years, 1 at five, and 5 are reported as walking late 
and badly." 

Fig. 47. 




(Gowers) Pseudo-Hypertrophic Paralysis. 



Duchenne and Drake reported cases in which convulsions were the 
beginning of the disease. Pain in the calves of the legs or back is some- 
times J;he first symptom, but is by no means one to expect as a rule. The 
appearance of the patient is most striking. The belly seems to be thrown 
out, the lumbar curve is increased, and the feet are widely separated. 
When the child attempts to walk, his movements are very much like those 
which we might expect to see in an individual laboring through a quag- 
mire. There is a certain amount of waddling, the legs being separated, 
and the feet planted at some distance apart. In progression the body is 
inclined to the side on which the foot is planted, and there is some jerk 
made in the effort to carry the foot forward. The patient rises from 
the sitting posture with some difficulty, as there is great impairment of 
the extensor muscles of the spine. This weakness is the cause of 
the difficulty in keeping his balance. The next stage of the disease is 
the development of the hypertrophy. Very often this change is an 
early one, and may follow closely after the commencement of the impaired 
motor power. The calves are generally first enlarged, and this enlarge- 



PSEUDO HYPERTROPHIC MUSCULAR PARALYSIS. 315 

ment may begin with the difficulty in walking, or within a period any- 
where from six months to several years after the beginning of the disease. 
This enlargement is not, however, always confined to the calves, but may 
affect the other muscles of the lower extremities, or even those of the 
upper. The glutei, gastrocnemii, deltoid, and many other muscles have 
been involved in cases reported by different observers. When the mus- 
cles are contracted, they stand out quite prominent, and in one of the 
cases reported by Barlow^ the child's appearance resembled that of the 
Farnese Hercules. The child is unwieldy and awkward, and though 
there is at this stage some increase in strength of some of the members 
used in locomotion, the child does not seem to have very much motor 
power, for he can scarcely walk. The muscles not hypertrophied may 
undergo an atrophic change, greatly adding to the deformity. In regard 
to the talipes that may be produced, the extensors are agitated by spas- 
modic contractions, which become more aggravated as the attempt to 
walk is persisted in, so that, after a few steps, the child is quite likely to 
fall. Dr. Gowers has devoted much time to the discussion of the sub- 
ject of muscular enfeeblement as a symptom."^ He alludes to certain pe- 
culiarities of the patient's behaviour, which are striking and pathognomo- 
nic. One of these is the manner in which the patient arises from the 
floor. Owing to the weakness of the muscles of the back, the little pa- 
tient always places his hands on his knees, " apparently to push the trunk 
up, to help the extension of the hip-joint-" This, Gowers says, is met with 
in no other affection, and I am inclined to agree with him. 

He first places his hand on the knee-joint, and when the knees are ex- 
tended he works his way up, putting his hand upon his trunk until he 
effects extension of the hip. 

" The reason why this action affords such help in extension of the 
knees, says Gowers, is obvious on a little consideration. In rising from 
the ground with the knees flexed, the weight of the trunk, resting on the 
hip-joint, is at the extremity (Fig. 48, W.) of a lever (the femur) of the 
third order, the fulcrum (F) being at the knee, and the power, the con- 
traction of the quadriceps extensor, being applied (P) between the weight 
and the fulcrum, — i. e., in the position in which it acts to least advantage. 
But by placing the hands on the knees, — i. e., on the end of the femur, — a 
large part of the weight (the larger the more the patient bends forward) 
is transferred to the lever (at W) close to the fulcrum ; the lever is, in so far, 
transformed into one of the second order, in which the weight is between 



iQp. cit., p. 11. 

2 Even so far back as 1830 Sir Charles Bell * recognized this as a striking symptom. 
" The paralytic debility of the muscles came on gradually : he was first sensible of it 
at a public school, about eight years ago. It began with a weakness in the thighs, 
which disabled him from rising; and it is now curious to observe how he will twist and 
jerk his body to throiv hhnself upright from his seat. I use this expression, for it is a 
different motion from that of rising from the chair." 

* Op. Cit. Third Edition, p. 432, case clxxx. 



316 DISEASES OF THE SPINAL CORD. 

the power and the falerum, and the power is economized in the greatest de- 
gree. Moreover, if the patient bend down, the centre of gravity may 
even be carried in front of the knee^, and then, if the hands grasp the knees 
firmly, the weight of the body, instead of being the weight to be moved, 
becomes a force applied to the upper end of the femur, eifecting the 
extension of the knee without the slightest action of the quadriceps ex- 




tensor, as any one may ascertain by observing the mobility of the patella 
in this attitude." The skin may often be greatly discolored in patches 
just as it is in infantile paralysis, and Duchenne has called attention to 
this mottling, which is due to modified cutaneous circulation, and is seen 
especially during the later stages of the disease. It is more often con- 
fined to the lower extremities, and the patches which at first appear as 
bright red discolorations gradually become more dusky as they are ex- 
posed to the air. This mottling is increased by muscular action, and in 
certain regions was found by Benedikt to be connected with local sweat- 
ing. The temperature of the hypertrophied muscles is higher by a de- 
gree or two than those that are atrophied ; and in the earlier stages elec- 
tric contractility is rarely affected, but in the later it is greatly dimin- 
ished. Of course this depends upon the fatty substitution which the 
muscular tissue has undergone, for but a small amount of normal muscu- 
lar fibre remains to be called into action by the electric stimulus. Put- 
nam, of Boston ^ reports a case of pseudo-hypertrophic paralysis with in- 
volvement of the tongue, which was broad and thick, and the face was 
smaller than it should have been. These conditions existed in addition 
to hypertrophy of the legs and thighs, back and arms — it is rare, how- 
ever, to find involvement of the face. 

^ Bost. Med. and Surg. Journal, Jan. 3, 1880. 



PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. 317 

Gowers ^ presents some cases of the disease in adults. The examples 
of lipomatous myo-atrophy, given by him, are seven in number. In all 
the disease began after twenty, and in several after forty or thereabouts — 
two being females. In two cases, those reported by Barth and Miiller 
there were autopsies made, —evidences of lateral sclerosis were found, 
and degenerative changes in the ganglion cells of the anterior cornua 
were disclosed. The lower extremities were affected in all the cases, 
though in several the hypertrophy was found in the upper as well. In 
three cases there was mental derangement. 

Causes. — Beyond the question of heredity it is impossible to go in 
our search for causes. One or two cases, however, are mentioned by 
foreign observers in which injury preceded the disease. Kesteven ^ re- 
ported one of these, and in this case the hypertrophy appeared at the 
fifteenth year. 

Poore's table^ includes the following examples of heredity : — 

" In two cases a maternal uncle and aunt had this disease. 

"In one case three maternal uncles and aunts had this disease. 

" In one case one maternal uncle and one half-uncle had this disease. 

" In one case three maternal half-brothers had this disease. 

" In one case a maternal half-brother, three maternal uncles, and other 
members on the mother's side, had shown the symptoms of pseudo-hyper- 
trophic par? lysis. 

" In thirty-seven instances, two or more belonged to the same family. 
It will be observed that it is only on the mother's side that this hereditary 
influence is transmitted ; while the disease shows itself almost exclusively 
in the males ; thus in a case reported by Duchenne, the mother, while 
she escaped, transmitted the disease to the children of her marriage. 
The same fact is stated in Foster's case. 

" In one case a maternal grandfather was hemiplegia. 

" In one case a paternal grandfather was insane. 

" In one case a father w'as insane. 

" In one case a father was intemperate. 

" In one case two brothers died of granular meningitis. 

" In one case a brother was an idiot. 

" In fifteen cases of the eighty-five the family history was good. 

" In thirty-three cases no mention of family history is made." 

Like other spinal troubles it is found that several members of the 
same family may be afilicted. 

Drs. -Steele and Kingsley ^ of St. Louis have reported several cases of 
pseudo-hypertrophic paralysis. Dr. Steele's cases were two brothers, and 
Dr. Kingsley's two sisters, aged ten and thirteen years. I have seen two 
cases in the same family, both of whom were girls, one being ten years 
old, the other seventeen. The youngest girl presented the lumbar curve 

1 Op. Cit., p. 62. 

2 Journal of Mental Science, vol. xvi., April, 1871, p. 48. 
^ Loc. cit. 

* Keported in '' Alienist and JS'eurologist," Jan., 1880. 



318 DISEASES OF THE SPINAL CORD. 

and arose from her chair with difficulty. Her thighs were firm, but 
smaller than they should be, but the calves and nates were hyper- 
trophied and hard, and it was impossible to take up any considerable 
amount of tissue between the fingers. She arose with difficulty from her 
chair. The older sister was helpless and could neither walk or stand, 
and in her case the disease had begun about the third year. I have also 
been informed of a family in which five children are affected. 

Pathology and Morbid Anatomy. — According to Barlow, the 
first examination of muscular tissue in pseudo-hypertrophic paralysis was 
made by Griesinger and Billroth in 1865. Griesinger excised a small 
portion of the left deltoid, which was hypertrophied and paralyzed, 
and microscopically examined the muscle, which resembled adipose 
tissue. He found the fasciculi in a perfect state, but surrounded by fat. 
Eulenburg^ and Conheim'' found the muscular fibres reduced to fully one- 
sixth their normal size, and in some localities there were masses which 
they supposed were the sheaths of empty sarcolemmse. 

Auerbach^ found hypertrophy of the muscular fibres, and an increased 
development of nuclei, but no interstitial fat deposit ; but this was in a 
patient who died during the early stages of the disease. Berger's* expe- 
rience was identical in an early case. Charcot^ examined a case (that 
seen by Berger), and found the psoas in a state of primary alteration. 
The primitive muscular bundles were separated by broad spaces of con- 
nective tissue containing cells of a spindle shape, and nuclei. Other 
muscles were likewise affected. The pectoral muscles, and those having 
a sacro-lumbar attachment, containing fewer nuclei, and the internuclear 
spaces were filled with wavy connective tissue. In muscles which had 
undergone still more advanced degeneration, there was some evidence 
of fatty deposit. In this case he witnessed three stages of degeneration. 
In the earliest there was atrophy of muscular bundles, indistinct longitu- 
dinal striae, and sometimes transverse striae. The sarcolemmse were filled 
with a hyaline substance. 

Duchenne^ denies the existence of empty sarcolemmse, and regards the 
enlargement due to an increase of connective tissue containing fat-cells. 
Dr. Gowers has made an autopsy which revealed a condition of affairs 
strikingly like that found by Charcot. The gastrocnemius muscle resem- 
bled a fatty tumor, " a yellow, greasy mass of fat, in which no trace of 
muscular redness could be perceived." The muscular fibres preented no 
granular degeneration, but ran through masses of fat-cells with more or 
less fibrous tissue intervening. In the " narrow fibres the transverse strise 
were farther apart than in the wider fibres." Various observers have 



1 Archiv fiir Heilkunde, 1865. 

2 Verliandlung der Berliner Med. Ges. i., pp. 101-205. 

3 Virchow, Archiv., vol. iii. p. 224. 

* Deutsche Archiv fiir Klin. Med., 1872, p. 303. 

5 Archives de Physiol., etc., 1872, p. 1. 

^ De r electrisation localisee, Paris, 1872, 3d edition, p. 604. 



PSEUDO HYPERTROPHIC MUSCULAR PARALYSIS. 



319 



examined the cord without finding any characteristic sign of trouble 
The motor-cells have as a rule been enlarged. Gowers rather adopts the 
view that pseudo-hypertrophic paralysis is primarily of peripheral origin, 
and refers to the observations of Tschirjew, who found that the sensory 
nerve fibres end in the interstitial fibrous tissue, and that the posterior 
nerve-roots were those generally affected in this disease. He therefore 
traces some connection between these facts, especially as the fibrous tissue 
is the primary seat of the changes. He holds that there is an ascending 
degeneration. 

Fig. 49. 





Appearance of Muscular Tissue. (Charcot.) 



Hitzig found an extraordinary increase in size of the arm of an adult, 
after injury near the shoulder joint, and the changed condition of the 
muscle was in every w-ay like that of pseudo-hypertrophic paralysis. 

In this case it was possible that there was an ascending neuritis, but it is 
also possible that the cerebro-spinal influence upon nutrition was suspend- 
ed, while sympathetic system exerted an influence which gave rise to an 
increase in fat deposit. The effect of certain kinds of injury or irritation 
is witnessed in various pathological processes, which are characterized by 
the rapid formation of new tissue or phenomena of nutrition. The exist- 
ence of hypertrophy and atrophy, at different stages of the same process, 
seems to me to be, in one instance, the commencing peripheral lesion, and 
in the other the result of a consecutive cerebral change. 

Diagnosis. — Progressive muscular atrophy seems to be the only dis- 
ease with which this condition may be mistaken. If the patient is seen 
at a time when the conditions of atrophy and hypertrophy coexist, it is 
not always easy to tell whether there is an increase of volume, or simply 
an atrophic condition of some muscleS; while others are of normal size ; 
but the other symptoms, alluded to, the exaggerated lumbar curve, and 
the waddling walk, should settle the question of diagnosis. Progressive 
muscular atrophy is also generally a disease which rarely appears at so 
early a period as does pseudo-hypertrophic paralysis. Increase of size 



320 DISEASES OF THE SPINAL CORD. 

from determination of blood to a muscle, such as that reported by Maun- 
der/ and sometimes fatty development, without paralytic symptoms, may 
deceive the incautious. 

Prognosis. — The disease is slowly progressive, and death occurs 
generally from some other disease. Poore reports thirteen deaths. 
Phthisis, pleuro-pneumonia, uncomplicated pneumonia, and croup appear 
to have carried off most of these cases ; and it seems as if pulmonary dis- 
ease bore some special relation to organic disease of the cord, particularly 
when trophic disorder accompanies such disease. In several of the 
spinal affections, especially when the anterior cornua are affected, there is 
generally the development of phthisis or other pulmonary maladies. The 
deaths that have been reported occurred rarely before the eighth year of 
the disease, and generally between the fourteenth and thirtieth. 

Treatment. — Duchenne reports two cures by the faradic current. 
This seems to be the only remedial measure that promises anything very 
encouraging. In the previous edition of this book I advised the abolition 
of fatty food. This I believe was a mistake, for when we remember that 
the nourishment of nervous tissue is more perfect when we consume fats 
it will be patent that they are serviceable. In fact an enlarged experience 
teaches me that the case will not do so well when fat does not form a part 
of the dietary. Massage should be employed at least every day. The 
well-known fact that phosphorus produces fatty degeneration should 
contraindicate its use. Systematic exercise with wooden dumb bells, and 
calisthenics are to be indulged in, and the patient should be made to walk 
for a short time every day. As to mechanical support not much is to be 
said. Gowers recommends Sayre's jacket, which I think in a few cases 
is excellent. The children who suffer for want of support of the vertebral 
column when the muscles of the back are weakened may be greatly 
helped by this or some other form of bodily support. Arsenic and mer- 
curials have been of service in the hands of some practitioners, among 
them Meryon. 

1 Med. Times and Gazette, March 27, 1862. 



POSTERIOR SPINAL SCLEROSIS. 321 



CHAPTER XL 

DISEASES OF THE SPINAL CORD (Continued.) 

POSTERIOR SPINAL SCLEROSIS. 

- Synonyms. — Progressive locomotor ataxia ; Tabes dorsalis; Ataxie 
locomotrice progressive; Locomotor asynergia, etc. 

When disease of the posterior columns of the cord exists we are fur- 
nished with a very interesting and striking train of symptoms, which 
are chiefly expressed by pronounced disturbance of the locomotory func- 
tion, diminished reflex excitability and defects in co-ordination and sensi- 
bility. So delicate has the matter of diagnosis become that the coarse 
symptomatology of five or ten years ago is not essential to the recognition 
of the affection. It has been found that cases of so called ''locomotor 
ataxia " may not be dependent upon disease of the posterior columns at all, 
but the symptoms occur as evidence of organic diseases of other parts, 
notably the pons. So, too, we meet cases of disease of the posterior columns 
without any of the pronounced locomotory troubles. Some of these patients 
are able to stand with closed eyes and do not walk with any peculiar stamp. 

Symptoms. — Every pronounced case invariably presents three 
marked symptoms : 1. Peculiar pains usually seated in the lower extremi- 
ties. 2. A simple atrophy of the optic disk. 3. An impairment of the 
reflex function, usually found in the tendon of the quadriceps, or shown 
in tardy action of the pupils. These symptoms are constant, but others 
are often found in conjunction. 

Most authors have divided this disease into three stages : 1. That 
characterized by pains and commencing impairment of the tendon re- 
flex. 2. That marked by the commencement and continuance of ataxic 
movements, etc. 3. The stage of decline in which the spinal lesion usually 
becomes extended, and various disturbances of nutrition are conspicuous, 
among them bed sores, general wasting of tissue, arthropathies, intercurrent 
phthisis, etc., etc. The first stage is usually the longest^ and may last 
many years, or it may be almost inappreciable. 

After exposure or prolonged dissipation, the individual may first notice 
the commencement of the disease in fulgurating pains which dart from the 
feet up the legs and thighs, and for the time he may suppose he has simply 
neuralgia or rheumatism. These pains are worse at night, and may be aggra- 
vated by damp or cold weather. They appear and disappear rapidly; and 
21 



322 DISEASES OF THE SPINAL COED. 

Clarke' calls attention to their tendency to move suddenly from one place 
to another ; remaining in one spot for some hours at a time, and then 
shifting to another. The pains are so prominent a symptom that they 
should never be disregarded. Some of the most advanced English clini- 
cians go so far as to say that with the presence of fulgurating pains, 
absent tendon reflex and white atrophy of the optic nerves, they can in- 
fallibly diagnose locomotor ataxia even when all other familiar symptoms 
are wanting. The pains are explosive, inconstant and erratic, never 
following the course of any particular nerve, and there is none of the con- 
stant soreness or defined pain so peculiar to the various forms of true 
neuralgia of the lower extremities. They may shoot through the soles 
of the feet, the heels, the inner part of the legs, the knees, or even the 
thighs. After a time, which varies from a few weeks to several years, 
there may be a most disagreeable sensory change of a lesser grade, which 
is confined to the feet. When walking, the patient complains that " the 
ground feels as if it were covered with fur, or a padded cushion." Some- 
times the sensation is likened to that produced by a stocking down at 
heel, or as if his shoe was filled with sand ; or, again, as if he were walk- 
ing in the air. There is no loss of muscular power, nor general loss of 
sensibility, in the preponderance of cases ; but there only seems to be a 
perversion of tactile sensibility, and that only limited to the sense of con- 
tact. By far one of the most interesting of the general changes is the 
absence of the patellar tendon-reflex. Enough has already been said 
about the importance of this symptom, and it remains for me to add that 
in the greater number of cases it is absent, though I do not take the ex- 
treme view held by many authorities. In a number of instances I have 
found it exaggerated instead of diminished, but I am now inclined to 
think that where it is aggravated there is an extension of the disease to 
other parts of the cord. In the majority of cases of locomotor ataxia 
-therefore no response follows the blow upon the ligamentum patellae and 
no dorsal clonus can be evoked by bending the foot. Heat and cold are 
appreciated, but the shape or size of the cold or warm object cannot be per- 
ceived by the tactile sense alone. Painful impressions are appreciated, 
but this is all. Circulation becomes sluggish in the limbs, and subjec- 
tive cold is felt in the lower extremities. If the individual is seated, and 
the hand of the examiner be held against the sole of the boot when 
the thigh is flexed, it will be found that he is generally quite able 
to extend the leg forcibly, but there may be sometimes a slight loss of 
power in subsequent stages when the anterior parts of the cord become 
-afifected. In the early stages of what may be called the descending 
form, there are various ocular troubles. Amblyopia, strabismus, 
or diplopia are among the more common, and it is not unusual 
to find some atrophy of the optic disk of either one or both eyes. In 
both forms of sclerosis of the cord, ascending as well as descending (these 



St. George's Hospital Reports, 1866. 



POSTEKIOR SPINAL SCLEROSIS. 323 

terms being applied with reference to the fact whether the disease begins at 
the upper part of the cord or vice versa), it is necessary for the patient to 
look at the objects which surround him in order that he may preserve 
his equilibrium. If he shuts his eyes, he is apt to topple over ; and it is 
utterly impossible for him to walk in the dark without holding on to 
something for support. The patient very often finds that when he closes 
his eyes, as he is about to wash his face, he is quite apt to pitch forward 
against the wall. This test is an important one, and if he is able to stand 
with his heels and toes approximated and his eyes shut, it may be inferred 
that either his disease has not advanced to a serious extent, or that it is 
not locomotor ataxia at all. The early ocular trouble is strabismus, 
which is an inaugural symptom, and is very often accompanied by am- 
blyopia ; and if the strabismus be single, the amblyopia will be on the 
same side. The pupils are sluggish, and sometimes are entirely insensible 
to light. They are as a rule both contracted, though they may be une- 
qual. Jackson, alluding to this state of the pupil, which he calls " Ar- 
gyle Kobertson's symptom," states that he believes it to be due to a loss 
of reflex activity, and but a link in the chain of disordered functions, 
which in the lower extremities is expressed by the absent tendon reflex. 
In eight cases reported by me, the tendon reflex was absent in four, and 
in two of these subjects there was neither impairment of vision nor any 
ocular troubles whatever ; but in the other two there were both optic 
nerve atrophy and pupillary changes, one woman having pin-point pupils.^ 
Various paralyses of cranial nerves may also follow, and ptosis is not an 
unusual symptom. NothnageP publishes the notes of a case where hy- 
persesthesia of the parts supplied by the fifth nerve was a prominent 
symptom. The lost power for localization is not uncommonly associated 
with this disease. With closed eyes, the individual is unable to place the 
tip of his finger on his nose, or upon any desired small point ; and, when 
told to touch the point of a pin held by an observer, he will be unable to 
do so, his finger missing the mark. When awaking, he is often undecided 
as to the whereabouts of his legs, or sometimes feels for a moment that 
he has none, and needs the aid of vision to see that there are such mem- 
bers. The nerve-fibres in the posterior columns lose their facility for the 
conduction of sensory impressions ; and it is sometimes several seconds 
before an impression made at the periphery is received at the sensorium, 
and appreciated by the individual. A symptom sometimes found in this 
disease, as well as in myelitis, is the sense of constriction which is referred 
to the waist. The bowels, in the early stages, are generally confined ; 
and there is some loss of control over the bladder, and constant dedre to 
empty that organ. Romberg calls attention to the fact that the stream 
seems to have no force, but falls to the ground on leaving the meatus. 
The individual is also troubled by erections during the early stages, and 



^ Boston Med. and Surgical Journal, Dec. 19, 1878. 
2 Berlin Klin. Woch., xvii., 1865. 



324 DISEASES OF THE SPINAL CORD. 

there is greatly increased sexual power. This, however, is diminished 
towards the end of the disease, and in males impotence follows. 

Miiller^ has noticed certain peculiarities in regard to locomotor ataxia 
which have not been fully noticed hitherto. He speaks of the urethral 
and rectal neuralgias, which are connected with tenesmus, and may be 
mistaken for other trouble. He also calls attention to the severe cough- 
ing paroxysms that indicate aifection of the pneumogastric, and he has 
also found that it is impossible, even by the use of pilocarpine, to induce 
sweating in the affected limbs. 

Irritability of temper, occasional mental disturbance, and loss of mem- 
ory are not rare evidences of intellectual failure, and occur at different 
stages. The electro-muscular irritability seems to be rather increased 
than diminished. The locomotory trouble appears quite early, and is 
one of the most distressing features of the disease. It begins by an awk- 
wardness in progression, and the feet fly out and are planted with a kind 
of jerk, the heel touching the ground first. The individual totters, and 
is eventually unable to walk at all without support, and the gait cannot 
be mistaken by any one who has once witnessed it. The sense of appre- 
ciation of weight also seems to suffer to a decided degree. Jaccoud^ 
found that this is lost to a great extent, and that there is a variation in 
the power to perceive weights on the two sides of the body. In one case 
mentioned by him, a pressure equal to 3000 grammes was perceived on 
the right side, and 2800 on the left. The pains before spoken of gene- 
rally disappear as the disease becomes confirmed, though they may last 
throughout. Fibrillary contractions are occasionally seen ; and, speaking 
of this, I have often witnessed a curious phenomenon which follows the 
use of faradism. I have noticed that when a muscle of one leg was agi- 
tated by clonic contractions, sometimes the same muscle in the other leg 
would be contracted synchronously with that under electric stimulation. 
The patient is generally timid, and easily disconcerted by any sudden 
noise or unexpected excitement ; and when crossing the street, the desire to 
avoid being run over on the approach of a wagon will produce such de- 
moralization as to prevent him from taking another step, and he some- 
times falls to the ground. There is rarely trembling, unless the disease 
has involved the upper part of the cord, when this symptom, as well as 
the inability to appreciate topographical points, will be marked. The 
patient is generally worried, anxious-looking, and woe-begone, and is full 
of complaints. The disease may last for from five to twenty years, and 
the patient is carried off by tuberculosis or some intercurrent pulmonary 
affection. Atrophy of all the muscles of the extremities generally takes 
place towards the end of the disease, and bed-sores and arthritic troubles 
are annoying and painful forerunners of death. 

Charcot has called attention to certain cutaneous eruptions which not 
infrequently are found with posterior spinal sclerosis, and which are 

1 Abstract in " Brain," vol. 3, No. 4. 

2 Op. cit., p. 341. 



POSTERIOR SPINAL SCLEROSIS. 325 

usually of a papulous and pustular character. He mentions the case of 
one person, who, while under treatment at La Salpetriere, presented large 
patches of urticaria, the appearance of which was coincident with the 
attacks of pain. Other writers have called attention to the existence of 
herpes in connection with the pain, and I myself have found patches of 
this eruption in connection with the early severe pains especially on the 
inner surface and back of the thighs. 

The eruptions generally mark out the course of the nerve which is the 
seat of pain ; Hutchinson, however, considers that this arrangement of 
the eruption is usually misinterpreted, and that, instead of the eruption 
following the direction of a nerve-trunk and its branches, the corymbi- 
form distribution of the skin-disease in reality corresponds with the course 
of the small vessels. 

Occasional but exceedingly interesting features of the disease are the 
joint troubles and certain trophic alterations in bone-tissue leading to 
decided brittleness and liability to fracture. Charcot was first to call atten- 
tion to these symptoms, and Buzzard, Weir Mitchell and others have written 
extensively about them since. Arthropathic changes may begin at any 
period of the disease, but are more common during the last stage. The 
joints of the lower extremities seems to be more frequently the seat of swell- 
ing than other parts, and this is true also, as Arnozan ^ points out, regard- 
ing the brittleness of bones, those of the trunk rarely undergoing change. 

The knees or ankle joints may be the seat of a cold, puffy, soft swelling 
of gradual growth, and nearly always attended by no increase in temper- 
ature, pain or evidence of inflammatory action. After a time it is possi- 
ble to detect a much greater degree of mobility, which is due to loss of 
substance, and it is an easy matter to twist the limb or dislocate the bone. 
At an early stage of the affection the patient may find it impossible to stand, 
because of the " turning " of the ankles. This is the case in one patient I 
have under observation ; but I regard a double symmetrical arthropathy a 
rare condition. It is possible to hyper-extend a limb, so that, for instance, 
a distinct fold of skin may be perceived upon the anterior aspect of the 
knee below the patella when the leg is carried forward, the patient's ex- 
tremity presenting the appearance of that of a child's doll. The foot 
may be everted to a great degree, or the thigh dislocated with great 
facility. The muscles about the arthropathy are often atrophied and feeble, 
and do not keep the limb in place. The articular surfaces may be felt, 
and will be found to be greatly reduced in size. 

Charcot and Raymond,^ in alluding to the disappearance of the heads 
of the long bones, relate the case of a woman, aged 52, who had been ill 
for many years. The autopsy revealed atrophy of the different processes 
of the humerus, femur, tibia, and scapula, with muscular degeneration of 
a fibrous character- In another case there was hip-joint affection, and 



1 Des Legions Trophiques, p. 86, 1880. 

2 Gaz. Medicale de Paris, Feb. 19, 1876. 



326 DISEASES OP THE SPINAL CORD. 

great brittleness of the bones, which broke when subjected to inconsidera- 
ble force, and afterwards united quite readily. During life the evidences 
of such arthropathies are sometimes numerous. They may be illustrated 
by the following case of Bourcere.^ 

The patient was a woman who entered La Charite April 8, 1875 ; she 
was middle-aged, and presented many of the symptoms of locomotor 
ataxia. These began about ten months before. The left leg seemed to 
be more affected than the right. Three days after admission the left 
thigh and buttock began to swell rapidly, and in a few hours the 
swelling, which was not oedematous in the strictest sense of the word, but 
hard and not painful on pressure, reached its maximum. It extended as 
far down as the knee, where it stopped abruptly. There was no fluctua- 
tion, nor any evidence of pus. The swollen part was almost double the 
size of the other limb, while the leg was shortened, and the foot was to 
some degree rotated outwards. There was also some swelling and hard- 
ness unattended by tenderness in the left iliac fossa. The swelling disap- 
peared almost entirely in a week, when vaginal examination was made, 
and a hard, smooth tumor was discovered, which apparently sprung from 
the pelvic bones of the left side. Pus was soon afterwards detected in the 
psoas sheath above and below Poupart's ligament. She became pros- 
trated, and died on the 6th of May. After death decided osseous changes, 
to be hereafter described, were observed. 

It has been found that in many subjects the bones undergo a chemical 
change which renders them liable to fracture. This fracture is sponta- 
neous and may be caused by some such simple movement as crossing the 
legs suddenly. The accident may be preceded for some days by an in- 
crease in the violence of the fulgurating pains and perhaps by some red- 
ness and swelling at a point. It is' not rare to find several fractures oc- 
curring after each other but there seems to be rapid repair. 

Locomotor ataxia may be associated with progressive muscular atrophy, 
or may sometimes terminate in general paresis of the insane. West- 
phal and Obersteiner, have written much upon the relation of the 
two diseases and their possible coexistence. 

Obensteiner,^ in an excellent paper upon locomotor ataxia and mental 
diseases, considers that mental symptoms are found in the greater pro- 
portion of cases of this disease, and calls attention to the fact that these 
expressions of psychical trouble may be very slight ; still, an acute ob- 
server will know that there is a departure from the normal intellectual 
condition. The patient's character is changed markedly. I have 
been often astonished at the apathy of an individual, or, on the other hand, 
at his irritability of temper, the violence of his anger, and his petulance, 
which are more than transitory evidences ; and they are as important 
symptoms, I think, as neuralgic pains, difficulty of co-ordination, etc. 
These changes were all well displayed in a patient of my own ; in 
health a most amiable, high-minded person ; in disease a morbid, bad- 

1 Progres Med., Oct. 9, 1875. 

3 Wiener Med. Woch., No. 29, 1875. 



POSTBRIOR SPINAL SCLEROSIS. 327 

tempered, wMning wreck. He had been noted for his gallantry on the 
field during the war ; but after his disease had become established, his 
character seemed to undergo a complete transformation. He wrangled 
with every one, became irritable over petty things, and made himself 
generally disagreeable. 

Obersteiner and Simon^ both agree that these patients should be exam- 
ined most carefully, and that the prognosis depends much upon the facts 
relative to mental alteration. The latter says : " It is not enough that 
the patient keeps himself quiet, and answers the questions relative to his 
age, how he feels, etc., and does not show marked delusions ; " these are 
not enough to assure us that his intellect is intact. 

In regard to the grave secondary mental changes, Tigges considers 
general paralysis to be a complication, while Obersteiner is convinced that 
the symptoms of this latter disease indicate a progression of the sclerosis 
upwards. He considers the lesions to be identical, and that it is only the 
seat of the change which has anything to do with the symptom expressed. 
He has also found, in general paralytics who have died, a sclerosis of the 
cord. 

M. Rey has observed nine cases of insanity associated with locomotor 
ataxia. In three of these the spinal sclerosis preceded the cerebral 
trouble, and in one the induration had extended from the posterior to the 
lateral columns. He found that the diagnostic difference between loco- 
motor ataxia combined with cerebral induration, and simply descending 
general paralysis of the insane, was the walk. In the former the patient could 
not stand with his eyes shut, and in the latter there was no difficulty of 
the kind. We may also take for granted that the walk of the ataxic is 
an early symptom, and that of the general paralytic a late one. Both are 
examples of defective coordination, and I think the latter is unwisely 
called paralytic. 

The difficulty of turning around is marked in ataxia, but it is 
not a prominent symptom in general paralysis. The individual walks 
steadily across the floor when told to do so, but when he has to retrace 
his steps, he'spreads his feet, and if the loss of co-ordinating power be at all 
great, he falls if he has no support. 

A case lately came under my charge where the sclerosis of the cord 
was ascending, and in an incredibly short time the cerebral symptoms 
which indicate the general paralysis of the insane were evident. 

M. F., aged 29 ; United States. On admission to the Epileptic and 
Paralytic Hospital, March 6, 1876, I was immediately struck by the 
woman's walk, which was ataxic in the extreme; and on questioning 
her and her husband we ascertained that about two years ago she had 
neuralgic pains in the legs and feet ; her walking became defective, and 
has continued so. Her mind was clear up to a short time. Her pupils are 
now unequally dilated, the left being the largest ; her lips tremble distinctly. 



lArchiv. fiir Psychiatrie, i. and ii., 1875. 



328 DISEASES OF THE SPINAL COED. 

Her tongue, when protruded, also quivers; when told to keep it quiet, the 
motion is greatly exaggerated. There is some ptosis of the left eye. When 
told to close her eyes, she is unable to co-ordinate delicate muscular move- 
ments. She cannot find the tip of her nose with her foreftnger by more 
than an inch. When her eyes are open, she cannot touch small points, 
such as the markings upon my watch-dial. When she stands with her 
eyes closed, she topples over almost instantly. When she walks, her toes 
are thrown out, and she comes down upon her heels. Her feet are planted 
far apart when she attempts to stand. When walking across the room, 
she reels, and has difficulty in turning around. When attempting to an- 
swer questions, she talks slowly, each word being uttered with some effort, 
the words containing the letter "f" and "p" are explosive, and the lips 
seem to have a great deal of work to form them. The consonants are 
slurred over ; for instance, the word " man" is pronounced " mah ; " the 
" I's " are dropped, as are many other letters. Her writing is very scratchy 
and irregular, although her husband says she formerly wrote an excel- 
lent hand. Mentally she is silly, and laughs immoderately at wrong 
times and without cause. She has no idea of time, but seems to know 
what she is saying. She has had several delusions, one of which was that 
she had been home the day before. 

May 12th, two months after admission. — Her walk is much worse; no 
urinary or other difficulty. There is some festination ; pupils still un- 
even. The difficulty in speech has markedly increased. Her tottering 
walk is striking. We at first thought she had syphilis, but this is not 
so. Being unmanageable and restless, she was transferred. Here, un- 
doubtedly, was an ascending condition, beginning with the pains and gait 
of locomotor ataxia, and ending with several early symptoms of general 
paralysis. 

Charcot has described a peculiar train of symptoms accompanying the 
pains of the earlier stages. These are the crises gastriques, which are ex- 
pressed by pains which begin in the groins, and run up the abdomen on 
either side, finally becoming fixed at the epigastrium. They are violent, 
and occur during the exacerbations of lancinating pain in the lower ex- 
tremities. During the time they last, there is violent palpitation, vertigo, 
and vomiting, the latter symptom occurring without relation to the con- 
dition of the stomach. If there be no food to be expelled from that or- 
gan, there may be a quantity of frothy and bloody liquid ejected. These 
crises last two or three days, and disappear quite suddenly. Buzzard has 
found that there is some connection between them and the arthro- 
pathies, and of nine cases with joint troubles, six presented the crises 
as a symptom. Some observers have noticed the appearance of ptosis 
during their existence, which gradually disappears. Stewart^ has seen 
several cases in which these symptoms varied, and instead of there being 
pain which started from the groin, there was deep-seated pain in the dor- 
sal and lumbar regions. 

Raynaud has called attention to a species of renal neuralgia which is 
not at all an uncommon complication. One of his cases, which was mis- 
taken for renal colic, presented lumbar pain, vesical tenesmus, retraction 

1 Med. Times and Gazette, Oct. 7, 1867, 



POSTEPwIOR SPINAL SCLEROSIS. 329 

of the testicle and other suggestive symptoms like those described by 
Miiller. There was temporary cessation after a few days, but a second and 
third attack followed. Charcot and other French writers have alluded to 
various additional visceral disorders, as found with this as well as other 
organic spinal diseases, and the functions of the kidney are sometimes 
greatly disturbed. I do not think that sufficient attention has been paid to 
forms of hysteria which resemble locomotor ataxia. These, I believe, are 
the cases which are cured. Isnard^ has extensively considered the func- 
tional form ; and Webb and Mitchell, of Philadelphia, have reported very 
interesting cases of genuine hysteria which counterfeited the organic dis- 
ease quite closely. 

Diphtheria is sometimes followed by a nervous condition that is apt to 
be mistaken for true locomotor ataxia. Seguin calls attention to the fact 
that the ocular trouble consists in paralysis of the ciliary muscle and 
consequent dilated pupils, with loss of accommodation instead of the or- 
ganic ocular change so marked in true spinal sclerosis posterior. This 
condition, too, is of short duration. 

Causes.— Dissipation has much to do with the development of this 
terrible disease, while onanism and venereal excesses, especially play an 
important part ; so that we may expect to find it among men about town, 
hard drinkers, and other people of bad habits. Injury, exposure to rain and 
cold; syphilis, and protracted mental excitement, favor its origin. These 
are rare cases, and I have seen one in which the disease suddenly appeared 
after injury, running a "peculiarly rapid course. At the Hospital for 
Epileptics and Paralytics there is such a case in the person of a German 
workman who broke his femur, the fracture being'simple. He was carried 
to the hospital and his injuries were treated in the usual way. After four 
or five weeks he began to have the fulgurating pains, and within four 
months there have appeared all of the pronounced symptoms of a grave 
case. He can hardly stand, and cannot walk without clinging to the 
sides of his bed. He has complete loss of the "tendon reflex," commenc- 
ing optic atrophy, immobile pupils, difficult deglutition, etc. Petit,^ in 
referring to the traumatic origin of the disease, does not allude to the 
rapid form, but contents himself chiefly with considering the influence of 
injury upon the established affection. He considers that falls upon the back, 
nates, or direct jarring of the cord transmitted by a^ fall upon the feet, 
are favorable to the development of the disease. Some sudden exposure, 
such as a fall into the water, or a night in the rain, may be the exciting 
cause, and several of my cases had such a beginning. Rosenthal ^ reported 
sixty-five cases, forty-six of which were males and nineteen females ; and 
of this number thirty-one were traced to libidinous excesses, seven to ex- 
haustion, and twenty- seven to cold and exposure. The youngest of these 

1 L'Union Medicale, 131, 131, 135, 137, 141, 142, 1862. Abst. in Lancet, Sept. 
30, 1875. 

2 Eevue Mensuelle, Xo. 3, 1879. 

3 Wien, Med. Woch., 1869, No. 251. 



330 DISEASES OF THE SPINAL CORD. 

patients was nineteen, and the oldest sixty-eight. The ages at which the 
disease appears is rarely before the thirtieth, and never after the sixtieth 
year. Heredity seems to have much to do with its development, for 
instance, Friedreich^ reports six cases which occurred in two families; 
and two of these patients were males, and four were females. The heads 
of the families were drunkards. Before the Clinical Society of London, 
Gowers^ presented the histories of five cases of locomotor ataxia in the 
same family. The mother had had chorea in early life, but the father 
himself was healthy, though some of his brothers had been insane. There 
were nine children in the family. " 1. A son, aged 39, with well-marked 
ataxy, which commenced at nineteen. He is just able to walk with 
crutches. There is inco-ordination of the arms and aifection of articula- 
tion. Sensation to touch is normal, that to pain is in the legs increased. 
The knee-jerk is lost. 2. A girl who died of fever at ten years old. 
3. A son, aged thirty-five, healthy. 4. A son, aged thirty-three, healthy. 
5. A girl, aged twenty-nine, in whom the affection commenced at eigh- 
teen. She can now scarcely stand ; there is weakness in the legs as well 
as ataxy, and also inco-ordination of the arms. Speech is affected, sensa- 
tion is normal, the leg-jerk is lost. 6, A son, aged twenty-six, perfectly 
well. 7. A son, aged twenty-three, considerably affected, — the disease 
showed itself at nineteen. * * * * 8. A son, 

aged twenty-two, reported to be well, but found on examination to be 
distinctly affected. * * 9. A son, aged nineteen, affected in rather 
a greater degree than the last." These two cases showed all the early 
symptoms — inability to stand with eyes closed, absent tendon reflex, and 
confluent articulation. Friedreich and Dr. A. Carpenter have also pre- 
sented cases — the latter, two cases in the same family ; but it is question- 
able whether Friedreich's cases were true locomotor ataxia. Syphilis, as 
I have said, is sometimes at the root of locomotor ataxia, and perhaps 
is the most fortunate cause to discover, as it greatly alters the prog- 
nosis of the disease. It must be understood that the lesion is purely 
syphilitic ; and the symptoms result simply from the presence of a gum- 
my infiltration or tumor in the posterior columns, and not from any in- 
duced sclerosis. Erb is disposed to lay great stress upon the frequency of 
the association of syphilis and the disease under consideration. 

Morbid Anatomy and Pathology. — The cord of the ataxic, 
when cut into, will present an appearance which is distinctive. The pos- 
terior columns will be found to be more gray and dark than they should 
be, and there may be hard deposits on either side of the posterior fissure. 
Beneath the microscope the peculiar thickening of the connective tissue 
will be found to have taken place at the expense of the nervous elements. 
Lockhart Clarke thus tersely describes the changes that take place : — 
" The morbid anatomy of locomotor ataxia consists chiefly of a certain 
gray degeneration and disintegration of the posterior columns of the spinal 
cord, of the posterior roots of the spinal nerves, of the posterior gray sub- 

1 Virchow's Archiv., xxvi., pp 391, 433. ' London Lancet, Oct. 16, 1880, p. 618. 



POSTERIOR SPINAL SCLEROSIS. 331 

stance or cornua, and sometimes of the cerebral nerves. A variable 
number, and frequently in the latter stages of the disease nearly all the 
fibres of the posterior column and posterior roots, fall into a state of 
granular degeneration and ultimately disappear. Usually the posterior 
columns retain their normal size and shape in consequence of hypertrophy 
of connective tissue which replaces the lost fibres. 

" In this tissue, at wide but variable intervals, lie imbedded the remain- 
ing nerve-fibres, with the debris of their neighbors in different stages of 
disintegration. In some places they are severed into small portions, or 
into rolls or lobular masses formed out of the medullary sheaths of white 
substance, which has been stripped from their axis cylinders. In other 
places they have fallen into smaller fragments and granules, which are 
either aggregated in the line of the original fibres or scattered at irregular 
distances. Corpora amylacea are usually abundant, and oil-globules of 
different sizes are frequently interspersed among them and collected into 
groups of variable shape and size around the blood vessels of the part. I 
am inclined to believe from my own investigations that in the course of 
the disease the posterior cornua of gray substance are more or less af- 
fected, and it appears to me to be a question whether they are not the 
first parts, or at least among the first parts that are morbidly changed. I 
have also shown that in some cases the deeper central parts of the gray 
substance are more or less injured by areas of disintegration. These lat- 
ter lesions, however, are not essential to the production of locomotor 
ataxia, the peculiar symptoms of which depend solely on lesions of the 
posterior columns of the posterior nerve-roots, and probably of the poste- 
rior cornua. The cases in which they occur may be considered as mixed 
cases, partaking of the nature of locomotor ataxia and common spinal 
paralysis." Charcot and Pierret do not consider sclerosis of the fillets or 
columns of Goll to be the essential lesion of the disease under considera- 
tion. They rather hold that the degenerative process begins in the lateral 
parts of the posterior columns. It has been shown that the nerve-roots 
themselves need not necessarily be affected, although the cornua may be 
degenerated most completely. 

Numerous interesting experiments have been made by Schiff",^ Ludwig,^ 
and others, some quite recently by Ott,^ and G. B. W. Field,* in this country, 
that are likely to change our views materially, not only with regard to the 
pathology of this disease, but of many others. These authors, with the excep- 
tion of the first-mentioned, hold that the lateral columns of the cord are 
the regions in which the conductors for voluntary impulses, inhibitory 
nerves, sudorific nerves, vasomotor impulses and sensations of pain are situ- 
ated, while the posterior columns " conduct tactile impressions and co-ordi- 
nation impulses." The gray matter, according to the carefully-made expe- 

^ Lehrbuch der Physiologie des nervensystems, 1859. 

' Ludwig's Arbeiten. 

3 American Med. Journal, Oct., 1879. 

* Journal of Mental and Nervous Disease, April, 1881. 



332 



DISEASES OF THE SPINAL CORD. 



riments of Field, has no office in the conduction of any of these impressions. 
It would appear, then, that so far as definite co-ordination and impairment 
in the reception of tactile impressions goes that the posterior columns are 
concerned ; but that the disease must involve the lateral bands of this 
region, and involve either commissurally or directly the lateral columns 
themselves, to give rise to the phenomena of pain that belong to locomotor 
ataxia. This agrees perfectly with the statement of Erb,^ that " the typi- 
cal form of tabes does not depend exclusively upon disease of the posterior 
columns of the spinal cord, but that other parts in the vicinity of the pos- 
terior columns must also be involved in the disease." If the columns of 
Goll are involved it will be later. The sclerosed parts of the cord in this 
disease are more commonly the lumbar and lower dorsal, although the 
cervical portion may be invaded as well. The case mentioned by Noth- 
nagel presented sclerosis of the entire posterior columns. 

The bones undergo remarkable changes before referred to, and 
after death the result of such arthropathic alterations may be seen in 
atrophy, exfoliation, shortening, and destruction of their articular surfaces. 
The appearance of old fracture is admirably shown in Fig. 50, which 
is taken from Charcot. A peculiar osseous change has been noted by 

Fig. 50. 




Appearance of Trophic Bone Changes in Locomotor Ataxia. (Charcot.) 

Luys and others, and this consists in wasting of the alveolar processes 
so that the teeth lose their support and drop out. 

The interest connected with the various phases of altered nutrition of 
bony tissue as a consequence of spinal disease, depend, to a great extent, 
upon the discovery of ^ Rauber and Talamon,^ the first of whom discovered 



1 Article in Ziemssen's Cyclop., vol. xiii., p. 602. 

2 Centralblatt No. 20, p. 305, 1874. 

3 Revue Mensuelle, 1878, vol. ii. 



POSTERIOR SPI>^AL SCLEROSIS. 333 

corpuscular termination of nerves in synovial membranes and ligaments. 
What the exact nature of this connection is remains to be studied. Tala- 
mon reports a case of arthropathy in which there was no disease of the 
large celjs in the anterior columns, and the researches of Charcot are 
equallv unsatisfactory in pointing to the trouble as a result of the same 
processes which enter to so great a degree in such other diseases as infan- 
tile paralysis and the like. The conclusions of ^Buzzard seem to 
throw light upon the subject, however. This writer, who, a^ has been 
stated, found that the crises gastrique were most frequent in patients 
who presented arthropathies, and that decided lesions of the radicular fibres 
of the pneumogastric probably existed, concluded that in the neighbor- 
hood there was another bulb or centre, which was likewise affected, 
and as a result the osseous changes occurred. ^ Arnozan is not disposed to 
accept Buzzard's view in their entirety, and is rather inclined to look for 
the lesion in the sensory region of the spine, and he is led to this opinion 
by the association of arthropathies, with an increase in the symptomatic 
pains in the extremities. 

If Buzzard's autopsical results bear out the connection between dis- 
ease of the nucleus of the pneumogastric, and the existence of crises and of 
arthropathies, it may raise the question of trophic changes as a result 
of general nutritive disorder. This seems plausible when we realize the 
fact that chemical alteration in the bones of ataxics has been found by 
^Keguard, who discovered that the phosphates had diminished in propor- 
tion, as the fatty matter had increased. 

The fractures of the bones of ataxics are characterized by the rapidity 
with which union takes place, the exudation of callus being remarkably 
rapid, as was shown in Richet's example, who died a few weeks after a 
spontaneous fracture. 

The cranial nerves are frequently affected, their course being 
interrupted by patches of degeneration. The induration attacks the 
periphery first, and extends to the centre, and the changes begin at the 
point of origin of the nerve and progress towards its distal end. The 
optic disk is nearly always found to be atrophied and blanched, but there 
seems to be no change in the size of the retinal vessels. There are often 
evidences of injection of the investing membranes of the cord or actual 
meningitis, and six cases which were reported by Friedreich presented 
opacity, and thickening of the pia mater, which was adherent to the cord ; 
I doubt if there are many examples in which some form of menin- 
gitis has not existed at some time or other. Charcot* alludes to the gray 
degeneration of the optic nerves as an evidence of the amaurosis that is so 
prominent a symptom, and he calls the pathological condition " nevrite 
parenchymateuse." Stilling has recently discovered a spinal root of the 

1 London Lancet, Feb. 7, 1880. 

2 Op. cit p 94. 

'Gazette Medicale de Paris, Feb. 7, 1880. 

* Lecons sur le Svst. nerveux, 2eme serie, 1 fascic. 



334 DISEASES OF THE SPINAL CORD. 

optic nerve which passes from the external corpus geniculatum, follows a 
deep course in the crus and is lost sight of in the medulla, and this 
suggests an explanation of the causation of the optic nerve atrophy even 
when there is no cerebral disease. 

Much of the interest belonging to this disease is connected with the 
phenomena of inco-ordination, and a lesion that may affect the integrity 
of the organs intended for the transmission and reception of visual, au- 
ditory, or tactile impressions will result in a loss of equilibriating power. 
According to Ferrier, the apparatus provided for the maintenance of 
equilibrium consists of : 1, a system of afferent nerves ; 2, a co-ordinating 
centre ; 3, efferent tracks in connection with the muscular apparatus 
concerned in the action. Of course lesions of one or all of these parts 
must result in a loss of balancing power. Perhaps the most important 
factor in the preservation of equilibrium is tactile sensibility. The frog, 
deprived of his skin, loses the power of co-ordination, for the co-ordinating 
centre is deprived of the exciting organ from which impressions are trans- 
mitted. So, too, may this loss follow sudden destruction of one of the 
peripheral organs of special sense. As has been shown by Volkmann, 
the exposed ends of the nerves are not sufficient to transmit the sensory 
impression, but it is necessary that their cutaneous terminations shall ex- 
ist. When the tactile sensation in the ataxic is blunted, or the impres- 
sions are interrupted in their upward course, as has been held by Schiff, 
we have a loss of co-ordinating power which is a striking feature of loco- 
motor ataxia. It is not necessary for consciousness to enter into equilibria- 
tion and co-ordination, for, as we well know, many acts are purely spinal 
in character, and become automatic to some degree ; and walking is no- 
tably one of these acquired automatic movements. Acephalous monsters 
have performed a number of acts which were strongly reflex ; and ani- 
mals from whom the brains have been removed are able to co-ordinate to 
a certain degree after the first shock of the operation has passed by. In 
the disease under consideration consciousness enters to a decided extent 
when the harmony of the co-ordinating centres is lost. This conscious- 
ness is exhibited in vertigo, and is exerted in the ineffectual effort to regu- 
late the actions of the limbs, the brain endeavoring to supply the lost 
automatic sense. Broadbent^ considers that there are two co-ordinating 
centres ; one in the cerebellum, and the other, as I have stated, in the cord. 
Vision holds the same relation to the cerebellar co-ordinating power that 
tactile sensibility does to the cord centre. For instance, a tight-rope walker 
would fall were it not for the aid of vision, although the tactile sensibility 
becomes so perfectly educated that it may take the place of the eyes in ena- 
bling the performer to regulate his actions when he is blindfolded. The 
tactile sense is of a lower grade, and when this fails the individual, as is 
the case with the ataxic, requires more than ever the aid of vision. In 
the normal condition he may close his eyes, and still be able to walk in 
the dark with some ease ; but if the tactile sensibility be affected, as it is 

^ Brit. Med. Journal, April, 1875. 



POSTERIOR SPINAL SCLEROSIS. 



335 



in the disease under consideration, and if the aid of his vision be denied 
him, he is utterly helpless to regulate his muscular movements. In the 
daylight he still has the power of helping himself, for vision comes to his 
assistance. In health this delicacy of co-ordination may be trained to a 
marvellous degree. I have repeatedly witnessed the feats performed by 
a French juggler, which illustrated the 
nicety of appreciation of weight it is pos- 
sible to arrive at by practice. He would 
throw into the air a heavy cannon ball 
and a pellet of paper, alternately catching 
them and tossing them up again, and the 
muscular movements were regular and 
harmonious, and indicated no effort what- 
ever. In locomotor ataxia this power of 
appreciation is sometimes lost to a marked 
degree. To some ataxic individuals a 
four-pound weight seems no heavier than 
one of two pounds would if the patient 
were in normal condition, and if his mus- 
cular movements were properly co-ordi- 
nated. 

One of the most interesting features of 
the disease is the question of absent tendon 
reflex. I have already expressed my 
doubts in regard to the universality of this 
symptom, but when the tendon-reflex is 
absent it indicates beyond all doubt a lesion 
of the cord above the third or fourth 
lumbar nerves as Prevost has demon- 
strated. Some authors believe the " tendon- 
reflex " to be purely a local phenomenon 
and among them, my friend, Dr. Augustus 
Waller,^ of London, has advanced the idea 
that there is no such thing as a true spinal 
tendon reflex, basing his conclusion upon 
the fact that the appearance of the clonic 
spasm occurs too soon after the application 
of the stimulus. This he demonstrated 
by the myograph. He, therefore, consid- 
ers that the phenomenon is due to a changed condition of the muscular 
contractility dependent upon some alteration in local innervation. Dr. 
Buzzard, on the contrary, in a series of elaborate papers, takes the 
opposite view, and says that it is a spinal reflex in every way, and that the 
shortness of interval between the application of the stimulus and the 
appearance of the contraction which is apparently inconsistent with phy- 




The Course of Posterior Nerve-Roots. 
(Clarke.) 



1 "Brain" Part X. 1880. 



338 DISEASES OF THE SPINAL CORD. 

siological mensuration of time, is quite possible when the sensibility of 
the nervous arc is exalted or in a favorable condition. He, therefore, can 
not take the physiological standard of time as the pathological. Prevost 
has in animals made pressure upon the aorta, and as a consequence the ten- 
don reflex was abolished and did not return until the pressure was remitted. 

The arrangement of the sensory fibers of the posterior columns is 
such that a lesion of either the white or the gray matter must in- 
terfere with the conductivity of sensory impressions. Lockhart Clarke's 
histological researches have thrown much light upon the subject. Ac- 
cording to him, the posterior root-fibers enter the cord in three direc- 
tions, some passing in at right angles to the longitudinal fibers of the 
posterior column, then passing across the same as well as the gray sub- 
stance, then bending and continuing longitudinally downward, next 
passing into the gray matter of the anterior cornua, and finally termi- 
nating in fasciculi which intermingle with the fibers of the anterior 
roots, or extend into the anterior columns. Other fibers (those of the 
second class) run across the posterior columns, or cross to the other side 
of the cord in the posterior commissure, or extend deeply into the poste- 
rior columns of the same side ; and others pass forward into the gray 
matter of the anterior cornua. The third kind of posterior spinal roots 
enter obliquely ; and certain fibers pass upwards and downwards, and 
become associated with fibers above and below them. The remaining 
fibers take an oblique course, and run upwards and downwards, the 
greater number taking the former direction and passing finally into the 
gray matter. It will be seen that a lesion afiecting the posterior columns 
of the cord will destroy the communication of the nerve-roots with the 
gray matter, or press upon the sensory fibres, causing peripheral pain. 
The communication with the parts above is destroyed, and should the 
sclerosis involve the anterior gray matter there may be paralysis and 
atrophy. A favorite theory, accepted by many writers, is that which 
considers that there are numerous centres of co-ordination in the cord, 
which are connected by longitudinal fibres, and that when these fibers 
are destroyed there results a species of inco-ordination. Dieulafoy^ divi- 
ded the posterior fasciculi at different heights, but without producing any 
marked defects in co-ordination, a result which seems to disprove this idea. 

Onimus^ explains the rigidity and awkwardness of the movements in 
locomotor ataxia by the theory that the stiffness of the muscles is perceived 
by the individual, and to overcome this he expends a greater amount 
of force than is needed for the particular act. The initial stiffness comes 
from the irritation of the anterior and lateral columns by the imeGhanical 
presence of the deposit in the posterior columns. 

Diagnosis. — It is important to distinguish locomotor ataxia from 
chronic myelitis, progressive muscular atrophy, chorea, cerebellar disease, 
and hysterical paraplegia. The former occasionally resembles ataxia, 
but with ordinary care no mistakes need be made. The paralysis of 

1 Th^se de Concours, 1875. * Gazette des Hopitaux, July, 1878. 



POSTERIOR SPINAL SCLEROSIS. 337 

transverse myelitis is very marked, and the implication of the bladder 
and sphincter ani causes the patient to void his urine and feces involun- 
tarily, which is not the case in locomotor ataxia. The strong ammoniacal 
odor of decomposed urine is itself almost a sufficient diagnostic mark. 
There is an absence of power in the legs, and none of the pain which 
characterizes sclerosis of the posterior columns. Ocular trouble and in- 
co-ordination are likewise absent. If the gait of the two diseases be com- 
pared, it will be found that in the former the legs will be thrown out with 
some degree of violence, and the heel will come down forcibly. In the 
paraplegia of myelitis, the legs will be drawn after each other, the inner 
edge of the sole scraping the ground ; and there is often a shrug of the 
body required to bring the feet forwards. The walk of the hemiplegic 
is also different, as one leg is swung forwards, the toe describing an arc, 
or else the foot is advanced in a straight line, the sole hardly clearing 
the floor. Myelitis in its early stages sometimes resembles posterior spi- 
nal sclerosis. The pain in the back, however, is characteristic, and the 
ulterior paralysis and bladder trouble are sufficient in themselves to clear 
up the diagnosis, though the constricting band about the waist may ex- 
cite our suspicion. Cerebellar disease has been spoken of by Radcliffe-^ 
as a condition that may sometimes be mistaken for locomotor ataxia. 
The movements are somewhat different, however, for the patient rolls and 
sways to a greater degree, and does not present the peculiar jerking gait 
of the ataxic. Local pain is another symptom peculiar to the cerebellar 
condition, and vomiting is also suggestive of this affection, but not of 
locomotor ataxia. Progressive muscular atrophy in its earlier stages 
may be mistaken for locomotor ataxia. The wasting of the muscles in 
anomalous cases may be imperceptible, and the unsteadiness of the indi. 
vidual may alone attract attention. This, with the pain, may raise a 
doubt as to the true nature of the malady. Hysterical ataxia, such 
as has been described by Webb, as a rule, is not symptomatized by pain, 
and the ataxia is not genuine. Syphilis, in some of i^s forms, also occa- 
sionally produces symptoms which are very much like those of this dis- 
ease ; and there may be paralysis of cranial nerves, with pain over the 
tibia, which may be misleading, when in reality no spinal disease exists. 

Chauvet,^ in his excellent article upon the influence of syphilis in the 
genesis of nervous disease, dwells upon the connection of syphilis with 
locoujotor ataxia, and quotes many authors to show that the co-existence 
of these two diseases is a pure coincidence. 

In a table showing their relation, eighty-five case* of ataxia are presented : 

Keporter. Syphilitic Patients. Ataxies. 

Fournier 24 among 30 

Vnlpian 15 " 20 

Feieul 6 '• 11 

Siredey 6-8 " 10 

Caizergues 8 '' 14 

^Op. cit., vol. ii. p. 683. 

■•^ Influence de Ja Syphilis sur les Maladies du Systeme Nerveux Central, p. 53. 
Paris, 1880. 
22 



338 



DISEASES OF THE SPINAL COED 



His conclusion is that syphilis has nothing to do with the actual de- 
velopment of primitive sclerosis of the posterior columns, but the presence 
of syphilitic deposit in this region may undoubtedly give rise to symptoms 
closely resembling those of the uncomplicated disease. 

Buzzard holds, however, that in nearly all cases of locomotor ataxia, 
either that some remote or recent history of syphilis is disclosed. 

Prognosis. — Among the number of cases reported by various ob- 
servers, I have not found many well-authenticated cures. An interesting 
fact, however, has been observed by Gowers, who states that in the cases of 
this disease he has seen — and they were a great many — that in families, 
those persons who reached the age of twenty-five without showing symptoms 
are exempt, although other members of the same family may have been 
affected. So important does he consider this fact that in one family in 
which there were three members affected, he recommended the application 
of a fourth member who presented himself as an applicant for a life-insu- 
rance policy. In regard to this question of age, it must be admitted that 
it is often a most difficult matter to say when the disease began, for 
the early pains are mistaken for other troubles. The following 
table gives, besides other facts, the ages and sexes of eight individuals 
affected. And it will be noticed that the disease began in these cases as 
follows : 37, 41, 40, 32, 45, 55, 36 and 42. It is barely possible that in 
some of these cases the first stage was not characterized by pain intense 
enough to engage the patient's attention. 

AN ANALYSIS OF EIGHT CASES OF LOCOMOTOR ATAXIA AT THE HOSPITAL FOR 
EPILEPTICS AND PARALYTICS, NEW YORK CITY. 



Duration, 



Probable 

Cause. 



Ataxic 
Members. 



Locationand 
Character 
of Jr'ain. 



Tendon- 

Reiiex. 



Disturbance 
of Surface 
Sensation. 



Ocular 
Symptoms. 



Cerebi-al 
Symptoms. 



years. 



57 2 



Syphilisand 
exposure. 

Unknown. 



Excessive 
venery. 

Unknown. 



Intemper- 
ance. 



Legs. 



Legs and 
arms. 

Legs and 
arms 

Legs and 
arms. 

Legs. 



Back and 

thighs. 

Arms, legs, 
viscera. 

Legs. 
Back, legs. 



Legs and Legs, 
arms. 



Legs and 
arms. 



Legs and 
arms. 



Absent. 



Increased 

to marked 

degree. 

Well 
Marked. 

Increased. 



Increased. 



Ansesthesia 



None. 
None. 



Atrophy of 
optic nerve, 

Atrophy of 
optic nerve, 

Atrophy of 
optic nerve 



Normal. 



Impaired 
vision. 



Dimness of 
vision due 
to atrophy 
of disks. 



Vertigo. 
None. 



Vertigo and 
epilepsy. 

Occasional 
epileptic 
attacks. 

None. 



Frontal head- 
ache (a co- 
incidence ?) 

None. 



POSTERIOR SPINAL SCLEROSIS. 339 

A peculiarity of the disease is the long intervals of improvement which 
occasionally occur ; and the disease may be stationary for years, but this 
is very rarely the case. I know of two cases which were so much im- 
proved, and remained so well for three or four years, that I flattered 
myself that I had cured them, but I have since seen a change for the 
worse in both patients. Balfour^ presented a case of locomotor ataxia 
which he claims to have cured. Pollard^ reports a case which began 
rather suddenly, and disappeared quite rapidly under treatment. Vidal,^ 
Duqueit,* and Herschell,^ all report cures. Vidal's patient, a man of 45, 
recovered in three months, and Duqueit's and Herschell's cases I consider 
doubtful as regards diagnosis. 

Treatment. — From the very nature of the disease, the ' treatment 
must be empirical. Nitrate of silver has been recommended by Wun- 
derlich, Charcot, Vulpian, and others, and has enjoyed great popularity 
as a remedy. Balfour, already alluded to, states that he cured a patient 
in three months by half-grain doses of this salt repeated three times a 
day, and by the use of a foot-bath in which a quantity of common salt 
had been thrown. The feet were also submitted to the influence of a 
faradic current passed through the water by proper appliances. The 
salts of silver may be used with considerable impunity without discoloring 
the skin, and an unnecessary degree of timidity has been shown in their 
employment. It is well, however, to begin with a quarter-grain dose, 
and it may be increased to a half, or even a grain, thrice daily .^ One 
case of my own was greatly benefited by this drug in combination with 
nux vomica. I have lately tried the phosphate of silver in one-third of 
a grain doses, with great success, and prefer it to the nitrate. In admin- 
istering the silver salts, it is well to give them continuously for several 
months, and then permit an interval to elapse before beginning again. 
In the early stages of the disease, I prefer the fluid extract of ergot, either 
in combination with the bromide of sodium or alone. It certainly seems 
to control the pain. For this purpose a simple remedy often aflbrds great 
relief If a few drops of the bi-sulphide of carbon are placed upon a 
piece of cotton in the bottom of a wide-mouth bottle, and the same be 
held for a few minutes over the painful spot, great ease will be obtained. 
Large doses of salicylic acid have an anodyne efiect. Among the more 
efficacious remedies to which I may allude is the sulphur bath, which is 
too little used at the present day, but has been praised by the French 
writers especially.'^ It seems to possess, in some cases, powers that are 

1 Brit. Med. Journal, 1875. 

2 Lancet, 1872, vol. i., p. 437. 

3 Gaz. des Hop., 127, 1862. 
* L'Union, 122, 1862, 

5 Bulletin Gen. de Therapeutique, Ixiii,, Oct., 1862. 

^ De I'emploi du nitrate d'argent dans le traitement de I'ataxie progressive. 
Bull. Gen. de Ther., 1862. 

' It has acted wonderfully in cases even of long standing, and deserves a faithful 
trial. 



340 DISEASES OF THE SPINAL CORD. 

almost marvellous. A small lump of sulphide of potassium is to be 
thrown into the tub in which the patient bathes, after which he is to be 
thoroughly rubbed. In regard to electricity, Meyer has reported several 
cures by the galvanic current. Onimus has used the inverse current, 
and I believe has done some good. The indication seems to be that the 
positive pole should be placed over the painful point, if one can be found, 
and the negative above. These cases in which cures have been wrought 
were, I infer, ataxic conditions of a functional character. Faradization 
of the muscles of the legs and thighs seems to comfort the patient more 
than anything else. Duchenne thinks that the muscular anaesthesia is 
benefited greatly by its use, and that co-ordination is improved. Dr. 
Drinkhard, of Washington,^ suggested that strychnine injected hypoder- 
mically, is a remedy which should not be lost sight of. In one case it 
promptly relieved the pain. He, however, compares the dangerous ap- 
petite of possible formation to that which grows out of the medicinal use 
of large doses of opium, and fears such trouble. I have used the actual 
cautery to the spine quite frequently, and have found that constant re- 
vulsive effect kept up for some weeks not only diminished the pains, but 
really improved locomotion. It should be applied down the whole length 
of the back, on either side of the spinous processes ; and, after the epider- 
mis has shrivelled off, subsequent applications are to be made. Belladonna 
and turpentine internally are recommended by Trousseau, and not only 
relieve the pain, but seem to help any vesical trouble that there may be. 
Should we suspect syphilis, the iodide of potassium will be indicated, and 
a saturated solution should be prepared, and given in increasing doses 
till forty or fifty grains are taken three times a day. Above all, it must 
be remembered that nutritious food, cod-liver oil, and moderate stimula- 
tion are perhaps more important than medication. I have observed the 
necessity for quiet and rest. Prolonged muscular exercise is bad, and 
drives are to be preferred to walking. The patient should seek a warm 
climate, for this disease is affected by damp, cold weather, very much as 
is phthisis, and a cold winter always tells upon the patient. The pains 
also are aggravated by cold and sudden changes, and I find Florida or 
other southern states to be the most comfortable places for these inva- 
lids. Much benefit has been derived from the dark room treatment, and 
I saw one gentleman who had been greatly improved by a few months of 
bed-rest in a dark chamber. 

Nerve-stretching has been tried in this disease with some apparent 
success, especially by Langenbeck ; but though two-thirds of the reported 
cases were helped, there was usually a relapse. 

Dissipation thwarts any chance of success, and late hours or a debauch 
will produce a relapse sometimes after encouraging improvement has 
taken place. Sexual indulgence (when it is possible) is likewise to be 
interdicted. 

^ Am, Jour. Med. Sciences, July, 1873. 



SCLEROSIS OF THE COLUMNS OF GOLL. 



341 



SCLEROSIS OF THE COLUMNS OF GOLL. 

(^Ascending Degeneration of Posterior Columns.^ 

The localization of myelitis in this part of the spinal cord is a matter 
of great difficulty. Charcot has studied the appearance of degenerative 
changes in connection with locomotor ataxia, and has found that when 
limited disease of the columns of Goll was found, the symptoms were 
those of ascending trouble. In his last work (1880) upon localiza- 
tion, he has presented illustrations which show the invasion of the disease 
process and its significance. 




(Charcot 



A. Total sclerosis of the posterior columns (columns of Goll and posterior root-zones), ordinary 
U)comotor ataxia. 

B. Sclerosis of the two posterior root-zones (columns of Goll exempt), locomotor ataxia. 
c. Sclerosis limited to the columns of Goll— ascend m^r degeneration. 

Cases of degeneration of the columns of Goll are cited by Charcot,^ 
Erb,' Simon and Lange. In all of those of the first writer the disease 
began below, and in fact the German investigators agree the disease begins 
as a rule by tumors or other forms of disease in the region of the chorda 
equina, and while at this inferior part it may result in a quite transverse 
myelitis, it extends upwards, being limited to the columns of Goll. This 
is beautifully seen in the upper part of the cord, where the degeneration 
may be well defined. The disease resulting from a transverse myelitis 
may be transmitted upwards, and degeneration of the columns of Goll be 
found ta extend as far as the floor of the fourth ventricle. 

Disease beginning at a higher level is very apt to be complicated with 
a morbid extension into the adjacent parts, so that the appearance figured 
in Plate A results, and this is explained by the arrangement of commissu- 
ral fibres found in this part of the cord. 

In nearly all cases it is impossible to make a diagnosis between the 
limited disease of the posterior columns and that which constitutes true 
" locomotor ataxia." In the cases of Charcot and Pierret the symptoms 



^ Lemons sur les localisation, p. 259, et seq., Paris, 1880. 
Article in Ziemssen's Cyclopaedia, p. 773, vol. xiii., Am. Trans. 



342 DISEASES OF THE SPINAL CORD. 

differ but little from those of the latter disease. It would appear that the 
success of our diagnosis should depend upon the recognition of irregular- 
ity in the appearance of symptoms, the absence of vertigo and ocular 
trouble ; and the predominance of other symptoms rather than the acute 
pains, which suggest disturbance more of the root-zones than any other 
part of the cord. Pierret^ has found the waist constricting band (parses- 
thesia), unsteadiness when the eyes were closed, and impaired power of 
preserving the equilibrium, but none of the striking symptoms of locomo- 
tor ataxia, in a case of uncomplicated disease of the columns of Goll. 

ANTERO-LATERAL SPINAL SCLEROSIS.^ 

Synonym. — Amyotrophic lateral spinal sclerosis (Charcot). 

When the anterior tract of gray matter and the lateral columns of the 
cord are conjointly the seat of the destructive changes, we find perma- 
nent contractures following loss of muscular power in both upper and 
lower extremities, together with extensive atrophy and subsequent bulbar 
symptoms. 

Symptoms. — The disease begins without fever ; with loss of power 
in the muscles of the upper extremities, which becomes quite marked 
after a short space of time, and then follows a general atrophy of the 
muscles of the paralyzed members. In this way the malady differs from 
progressive muscular atrophy, in which one group of muscles, or even a 
single muscle, becomes atrophied before others, and in advance of any 
paralysis. Charcot calls this wasting process ^ atrophic en masse." . At- 
tendant upon the paralysis are deformities, and these are highly charac- 
teristic of the disease, and result commonly from contractures of muscles 
which are less paralyzed than others, so that the stronger muscles over- 
come the weaker. The flexors of the hands are commonly affected, and 
these members are flexed and distorted, the fingers being drawn up so 
that their ends press into the palms, as is the case in other forms of post- 
paralytic contractures. The arm may be adducted to the side, and forci- 
ble adduction or extension is impossible. Pain is usually produced by any 
violent effort made to overcome the deformity, and the physician is obliged 
to desist. The patients are able, though their muscles are paralyzed and 
contracted, to perform certain limited movements, but the same tremor takes 
place which we observe in other forms of sclerosis when a voluntary effort 
of any kind is made. In the late stages the emaciation is complete, and 
the appearance of the hands resembles that seen in progressive muscular 
atrophy. There are the elevated thenar eminences and the flat fore- 
arms, but the limb is still contracted. Charcot alludes to a condition 
which sometimes affects the muscles of the neck, so that they are con- 
tracted to such a degree that the head is fixed and immovable. He'relates 

1 Archives de Physiologie, etc., 1873, p. 74. 

2 I prefer this compound title, as it obviates confusion and more definitely ex- 
presses the seat of the disease. 



ANTERO-LATERAL SPINAL SCLEROSIS. 343 

a case where the muscles of the inferior maxilla were so contracted as to 
greatly interfere with mastication. 

The progress of the disease is marked by involvement of the tongue, 
and later by the destruction of the nuclei of the several cranial nerves, 
so that various losses of special function rapidly follow, and death termi- 
nates the patient's sufferings. The inferior extremities are paralyzed in 
their turn, and are the seat of contractures which resemble in some re- 
spects those of the upper extremities, so that his condition is one 
of helplessness. The legs become rigid when he attempts to walk, and 
are agitated by tremors so that he is obliged to desist. The contrac- 
tures in the lower extremities are much more marked than in the upper, 
and when finally the victim seeks his bed he presents a most abject 
and pitiable appearance, the legs being twisted and contracted so that he 
requires the services of an attendant, as he is utterly unable to do any- 
thing for himself.^ Fibrillary tumors may be present just as in progres- 
sive muscular atrophy, but are not so constant as in the latter disease. 
The symptoms which usually herald the approaching end of the disease 
are those which indicate invasion of the bulb. Paralysis and atrophy of 
the tongue, vermicular movements of that organ, and affections of speech, 
are among these, and the orbicularis oris and facial muscles are next 
attacked, when there may be drooling of saliva and other indications of 
bulbar degeneration. In short, the symptoms are very much like those of 
bulbar paralysis. Sooner or later the pneumogastrics are implicated, and 
death follows. The disease runs its course in from six months to three 
years. 

I have been so fortunate as to see one case of this disease, the note of 
which I append. 

E. S., laborer. About one year ago he noticed an awkwardness in 
holding his spade, and when engaged in the excavation of a cellar he 
was unable to throw up the dirt, and at the same time felt unjoleasant 
formication and cramps. These became so distressing that he applied 
liniments to his wrist and arms, but without any relief whatever. He 
consulted a medical man, who tried electricity, with no good effect, 
and after passing two or three months without treatment, he came 
to me, and I was able to make a diagnosis almost immediately. Both 
hands were strongly flexed, and the muscles were greatly atrophied. The 
index finger of the left hand alone escaped contraction. There was some 
rigid contraction of the forearms, while the arm was carried upwards 
and forwards by the muscles of the shoulder and thorax, and there was 
no movement of the elbow or wrist. Fibrillary contractions were ob- 
servable in the triceps, pectoralis major, and biceps. When I endeavored 
to straighten the arm he suffered great pain, and begged me to desist. 
There seemed to be no involvement of the lower extremities, and the pa- 
tient walked without embarrassment. 

Seeligmuller ^ saw several curious cases, which were not only valuable 

1 There is never cutaneous ansesthesia, the bladder and rectum are not affected, 
and there is no tendency to bedsores (Charcot.) 

2 Deutsche Medicinische Woch., April 22 and 29, 1876. 



344 DISEASES OF THE SPINAL CORD. 

as instances of heredity, but which illustrated the course ' of the 
disease.^ 

The cases came under the observation of Seeligmuller in January, 1876. 
The family history, which was carefully inquired into, was remarkably 
good, with one significant exception — that the parents were first cousins. 
There was no evidence of syphilis. Seven children — six girls and one 
boy — were the result of the marriage. Of these, the eldest, aged eleven, 
was quite healthy ; the second, aged ten, was in an advanced stage of the 
disease ; the third was, if anything, worse still, but was not seen ; the 
fourth, a boy, aged six years and nine months, was in the middle stage ; 
the fifth and sixth were healthy ; and the seventh, aged one year and nine 
months, was in the first stage of the affection. The disease began in a 
similar way in all. Strong and healthy when born, they continued so up 
to the age of about nine months, when a change took place. Able pre- 
viously to sit up without trouble, they began to lose this power, and 
would fall to one or other side ; later, the head and chest sank forward. 
At the age of two years attempts were made to teach them to walk, but 
their eflforts resembled those of an infant six months old. This was ex- 
emplified in the youngest patient, who, when supported under the armpits, 
made jumping movements, the legs being raised from the ground simultane- 
ously. Subsequently the children learned to support themselves with diffi- 
culty against a chair, but even this power was lost again. The boy had lately 
been rapidly losing ground in this respect ; he could still, however, drag 
himself about in his bed, and, by means of a specially constructed chair 
on wheels, could walk. The two eldest children, when supported in the 
upright position, could not put one foot before the other ; even when 
lying down, they were unable to move, the upper extremity being useless 
as supports. The youngest girl could sit for a short time on the table, 
but cried all the time, and soon fell to one side; she sat with her head 
and chest inclined forwards, the spine equally curved, and the thighs 
greatly abducted ; when on the lap, however, she could move her arms 
and legs in all directions. 

Contractions at the joints were present in a high degree in the three 
eldest. In the eldest girl the hands were adducted and pronated ; pain 
was produced by attempts at passive supination, and the hand, when re- 
leased, jerked back to its old position. The fingers were rolled in towards 
the palm, but she could still extend them, though very gradually and 
with great difficulty. The grasp was still perceptible ; the right better 
than the left. The elbows were slightly bent, and nearly fixed. The 
knees were half flexed, but could, with great force, be moderately ex- 
tended or flexed still more, though on leaving them they sprang back 
with a jerk. The feet were in the position of advanced equino-varus ; 
the tendines Achillis were perfectly rigid. All attempts at passive 
movement produced considerable pain. The boy was put under the 
complete influence of chloroform, and the rigidity of the joints then so 
increased that the whole body could be raised from one leg and held out 
like a piece of wood. The youngest girl has so far no contractions. 

Atrophy of the muscles was marked in the two eldest under observa- 
tion. With the exception of those of the face, it was evenly spread over 
the whole system. The wasting in the case of the girl was considerable, 
so that the head seenaed too large for the attenuated neck, and was 
moreover unsteady. The parents were confident that in all three the 

^ London Medical Kecord, June 15, 1876. 



ANTERO-LATERAL SPINAL SCLEROSIS. 345 

"wasting was not visible for some time after the loss of power showed 
itself. 

In the eldest child the reaction of the tibial and peroneal nerves was 
normal with both currents ; but the irritability of the muscles was de- 
cidedly lowered everywhere. Of those on the back of the forearm, the 
supinator longus alone responded promptly. In the youngest girl, fara- 
dic excitability of both nerves and muscles was perceptibly lowered in all 
extremities, but especially in the left lower. Galvanic excitability was 
lowered in the same way, and in the tibial nerves was almost nil. Ordi- 
nary reflex irritability not increased. That of the tendons, however, was 
present in a high degree in all. Fibrillary contractions were markedly 
present in the eldest girl, and could be produced by simply blowing on 
the skin. Sensibility was normal in all. 

Of the symptoms noticed by the parents, that which made its appear- 
ance last was the gradual loss of the power of speech. Thus, in the two 
eldest girls, this was tolerable until their sixth year, when it became less 
and less distinct, until finally only inarticulate nasal noises could be made. 
In the girl, the lips, soft palate, and uvula were all paralyzed, and the 
tongue lay in the mouth like a mass of dead flesh ; its tip could be ad- 
vanced only as far as the teeth. In the boy the same symptoms were 
present, but in a somewhat less degree. The youngest child could say a 
few words, but these had a slightly nasal tone. Swallowing in the two 
eldest girls was difficult ; in the boy, tolerable. The form of the skull 
was unusual in all, but especially so in the eldest. It was very broad 
between the parietal eminences, and very undeveloped in the frontal re- 
gion. The forehead was low, and the head appeared altogether too small 
for the face. In the eldest girl the features were coarse ; the expression 
was vacant, but usually amiable ; the pupils were much dilated ; the 
saliva flowed continuously out of the half-opened mouth.; and, indeed, 
her general appetirance was that of an idiot; though, in point of fact, 
the intellect was very fairly developed. The faradic excitability of the 
facial muscles was decidedly increased ; the galvanic was normal. 

Causes. — No definite causes are known, though exposure is believed 
to have much to do with its origin, and Charcot's cases are thus accounted 
for ; but we may also consider that dissipation and hereditary influences 
play an important part in the etiology of the affection. It is a disease 
which rarely occurs before adult life, so far as we are enabled to judge 
from the limited number of cases which have been reported. 

Morbid Anatomy. — To Charcot belongs the credit of having made 
the distinction between progressive muscular atrophy and-lateral amyotro- 
phic sclerosis. Previous to 1867, examples of this affection were considered 
to be cases of progressive atrophy, which were anomalous in the fact that 
the lateral columns were affected. Jaccoud ^ considers the sclerosis as circum- 
scribed or diffused. Like sclerosis in other regions, the tissue-changes may 
be observed wiih the naked eye, either invading the white or the gray 
matter separately, or more often together. In this case the lesions are of 
ancient date. The connective tissue is firm and shrunken, and the color of 
the hardened spot is gray or pinkish-gray. The meninges may be adherent 

1 Op. cit., p. 319. 



346 DISEASES OF THE SPINAL CORD. 

to the cord if the sclerosis be circumferential, but it is more common in 
uncomplicated sclerosis to find no such change. The microscopical appear- 
ances are like those seen in locomotor ataxia, as the character of the lesion 
is identical, the only point of difference being the location of the tissue- 
change. Clrcumscrihed sclerosis is more rare than the diffused variety, 
and few cases have been observed. Of examples referred to by Jaccoud, 
in one the lesion was confined to the lumbar enlargement, and invaded 
the entire anterior columns and a part of the lateral columns ; and in 
another, in which the autopsy was made by Frommann,^ " the sclerosis 
occupied the lumbar segment and the inferior portion of the dorsal region. 
It involved in different degrees all the white matter, and the gray was not 
affected except in the gelatinous substance and in the parts of the poste- 
rior cornua which bounded the lateral column.'^ The sclerosis has in- 
volved the entire antero-lateral columns, the anterior columns alone, or the 
lateral and the lateral and posterior conjointly. In diffused sclerosis, no- 
dules are found in various parts of the brain and cord, but the predomi- 
nance of the sclerosis in the antero-lateral column gives prominence to the 
symptoms which I have described. 

Diagnosis. — It is possible that this disease may be confounded with 
either progressive muscular atrophy, lateral sclerosis, or spinal paralysis. 
In the first we find a train of symptoms consisting of neuralgic pains, 
atrophy of single muscles or groups, and involvement of other muscles 
progressively, and secondary paralysis. There are besides no spasmodic 
contractions. In lateral sclerosis there is no atrophy beyond that result- 
ing from inaction. In the disease known as spinal paralysis the lower 
extremities are generally affected first, and reflex excitability and electric 
irritability are diminished, which is not the case in the disease which has 
just been described. 

Prognosis. — About as bad as it can be, though very few cases have 
been reported. It would seem that there should be as much chance in 
this disease as in lateral sclerosis, which is sometimes cured, but such is 
not the case. 

Treatment. — I think it may be said that no treatment offers any 
real assurance of success. 



Anatomie des EiickenmarkS; Jena, 1864. 



DISEASES OF THE LATERAL COLUMNS OF THE SPINAL CORD. 347 



CHAPTER XII. 

DISEASES OF THE SPINAL CORD— (Continued). 

DISEASES OF THE LATERAL COLUMN'S OF THE SPIRAL CORD. 

The various forms of disease of this part of the spiDal cord may be ta- 
bulated with reference to their symptom significance as: 1. 'Infantile 
spastic paralysis (spastische spinallahmung of Erb/) 2. Functional 
spastic paralysis (Storungen-neurosis of Berger.') 3. Hysterical spasmo- 
dic paralysis. 4. ^ Adult spasmodic spinal paralysis (Primary symmetri- 
cal lateral sclerosis of Charcot.) 

1. Is of course an affection present at birth, or commencing very soon 
after, and has continued through life in all the cases so far observed. 

2. Is not confined to any age, but so far the reported cases have been 
among adults. It has its analogue in functional paralysis and distur- 
bances of sensation dependent upon ischsemia of other parts of the cord. 

3. A disease of adult life, and so far has been seen only among women. 

4. A disease of adult life, rarely beginning" before the twelfth year, and 
sometimes curable. 

Symptomatology. — The positive symptoms of lateral column disease 
may be enumerated as paresis, with rigidity and contractures, and in- 
crease of all forms of reflex excitability, and especially that of the tendons. 

Of the negative symptoms we speak of the absence of atrophy, and 
bladder and rectal complications as well as true ataxia, and it may be 
stated that cerebral symptoms are never present. 

In the various forms of lateral disease, there is great irregular- 
ity in the lo?s of power, either in extent or period. In the infan- 
tile cases it may date from earliest life, and only be recognized at the 
time when the child is naturally expected to walk ; or it may gradually 
occur later in life as the initial stage of the disease. This rule holds 
good in every case ; for in the examples of secondary trouble there is 
always an early paresis even though there may be preceding anaesthesia 

^ Memorab, Monatsschaft, f. r. p. a. xii. Jahr. 12 H. 1877, p. 529. 

2 Centralblatt, 1878, p. 13. 

5 Seguin, Strumpel * and others inclined to think that spasmodic spinal paralysis 
may be produced by a variety of lesions among which are compression myelitis, tumor 
and cerebro-spinal sclerosis. This is undoubtedly true to a certain extent but it must 
be acknowledged that the spastic paralysis thus induced is seldom uncomplicated, and 
that sensory and other irregular symptoms are produced as well. 

*■ Archiv. fiir Psychiatric, x. p. 676, and xi. p. 27. 



348 DISEASES OF THE SPINAL CORD. 

or other sensory troubles. The early signs of impaired power are manifested 
in a variety of ways : the individual easily tires ; and a short walk produces 
a sense of fatigue referred to in the flexure of the knees. He leaves 
his bed with difficulty, and his legs are used awkwardly ; and as the day 
advances he feels more disinclined to walk or move about. Should the 
upper extremities be those first affected, he finds himself unable to grasp 
his tools as forcibly as he once did If he is a clerk, his pen is used 
clumsily and its point is not kept in contact with the paper, but traverses 
the lines unsteadily, so that the writing is exceedingly tremulous and 
without character. The paresis becomes more decided, and is con- 
nected with spastic rigidity. Later on, as it grows more profound, it re- 
sembles, to some extent, certain well-known forms of paralysis — but there 
is no anaesthesia. 

This similarity is very decided in the hemiplegic forms, but the loss of 
power, however, is likely to affect the different members in a decidedly 
irregular manner, perhaps appearing in one leg first, then the other, and 
finally the arms ; or it may affect one leg, then the arms of the same side, 
and then those of the other side. The limbs may be the seat of paresis, 
which varies on both sides in profundity. Although sclerosis of the lateral 
columns on one side only giving rise to a hemiplegia of spinal origin (such 
as have been especially alluded to by Berger), may occasionally occur, it 
will be seen, from an insi^ection of reported cases, that in primary disease 
of the lateral columns, and even in the transverse varieties of secondary 
degeneration, that the paresis is paraplegiform. The paresis is suggestive 
of extensor paralysis ; and in supine posture in the advanced stages, the 
patient is usually unable to raise his heels more than four or five inches 
from the surface upon which he may be lying, and in most cases not even 
to this extent. Combined with the paresis is a certain amount of rigidity, 
which exists in every case, and varies from a simple spastic condition to 
one attended by absolute contractures. The paresis and rigidity, gradual in 
their method of appearance, are rarely universal ; but in nearly every case 
of either primary or secondary disease, ultimately affect both extremities. 
The earliest evidences of motor irritation are shown in the muscles of 
the lower extremities, notably in a certain spastic stiffness of those of the 
calf and of the posterior and inner aspects of the thighs, and as a result 
of this trouble, there is great rigidity where passive movements of the knee 
and ankle joints are made ; and when any attempts at locomotion or other 
movements requiring use of the feet are essayed, th-ese members become 
extended and quite rigid. This rigidity, like the tendon reflex, seems to 
be increased by warmth (though in a case reported by Kussmaul the reverse 
was observed), and it is especially troublesome when the upright position 
is assumed. When the knee is bent and the leg flexed, it will be found 
that the hamstring tendons stand out as rigid cords, while there is more 
or less resistance to flexion of this kind. The gait of patients suffering 
from disease of the lateral columns, has been called by the Germans 
" spastichergang ; " and its peculiarity depends upon the combination of 
paresis and muscular rigidity — the latter being increased by the act of 



DISEASES OF THE LATERAL COLUMNS OF THE SPINAL CORD. 349 

putting the foot to the ground. In the beginning, as a result of the loss 
of power, the patient constantly stubs his toes, which comes in contact with 
any little elevation which may be in the floor or surface upon which he 
walks. Afterwards the embarrassment is increased by the spasms which 
involve the muscles upon the posterior aspect of the leg ; and there occurs 
a specifs of talipes equinus, the toes, however, being usually flexed. 
The patient, from the first, walks with difiiculty, his feet becoming 
interlocked and entangled, and through a rigid contraction of the thighs, 
the knees are brought together ; and as a result of friction these internal 
surfaces will be fouud to be callous and roughened. The knees are often 
sunken, so that the anterior leg or thigh surfaces form almost an obtuse 
angle, and in the advanced forms of disease of this kind, these deformities 
of extension and adduction become very conspicu^ us, and the patient 
becomes so helpless that he requires a cane or crutches. 

In the upper extremities deformities and spastic rigidity are neither so 
markedly or constantly shown, although in rare cases terrible distortions 
of the variety described by Charcot^ and Strauss^ are sometimes seen. 

As a later result of continued and persistent contractions of the muscles 
ending in the tendo-achillis, and in other tendons, there may result condi- 
tions either of talipes equinus, valgus and varus, and the patient's efforts 
to walk cause him very great distress, as his weight comes upon his dis- 
torted foot. 

A peculiar deformity, first noticed by Charcot,^ and which I have 
several times observed,'' is the abdominal contraction which gives rise to a 
very pronounced anterior curvature of the body ; and, as a result, there is a 
protrudeut abdomen and a deep fissure below the lower border of the ribs. 
In such cases there is usually some local wasting of the muscles of the 
back, jast as there would ba in any muscles subjected to disease, and kept 
upon a stretch for a long period of time, but in no respect is there true 
atrophy from deficient central innervation. The head is never afiected 
by motor trouble ; and there is no paresis of the muscles of the neck. 

One of the marked distinguishing features of disease of the lateral 
columns, is an exaggeration of reflex action which is evinced in several 
ways. Not only is the skin reflex increased to a decided extent, so that 
tickling, simple contact of the clothing, or even blowing upon the surface, 
will provoke variations of motility of irregular and disorderly character, 
but the "tendon-reflex," which plays an important part in all these cases, 
is excited. There are a number of manifestations of motor irritation 
which have been described independently ; but I am of the opinion that 
they all resemble each other, and all depend on activity of the so-called 
"tendon-reflex." The so-called Knie or Uuterschenkel Phaaomen 
and Fiiss Phanomen of Erb and Westphal, are simply varieties of 

^ Lepons sur les Maladies du syst., N., 1872-3. 

2 Op. cit., p. 16. 

^ Lepons sur les maladies du syst., N. 1878. 

* New York Medical Record, Oct. 28, 1878, p. 323. 



350 



DISEASES OF THE SPINAL CORD. 



chronic movements which follow forcible stretching of different tendons 
when the knee and ankle joints are bent in flexion, and are varieties of 
tendinous reflex. The simplest and usually most easily produced move- 
ments follow flexion of the foot. 

From an inspection of a large number of cases, I am certain that the 
value of this test depends very much upon the degree of flexion ; for if 
too little stretching of the tendo-achillis is made, the results will be as 
unsatisfactory as when this tendon is over-tensely drawn. 

To evolve this clonic movement (dorsalklonus of the Germans ; trepi- 
dation provoquee of Charcot), the operation is to grasp the leg (but not 
too tightly) with the left hand, while the palm of the right hand is 
brought in apposition with the plantar surface of the patient's foot, which 



Fig. 53. 




is passively flexed, so that the toes 
are forced slightly upwards. The 
foot is kept in this position, and 
usually in a very short space of 
time, often immediately, there is 
manifested a clonic spasmodic 
agitation of alternate flexion and 
extension. 

Sometimes such motor disturb- 
ance continues after the hand is 
removed, the patient's foot being 
extended, the heel retracted by 
the muscles uniting in the tendon 
achiliis ; and while raised several 
inches from the floor, it is agi- 
tated for some time, — several 
seconds usually, but I have seen cases in which the trepidation lasted 
nearly half a minute. This trepidation is extremely variable ; and, like the 
movements following the tapping of the tendon, it presents different features 
in different cases and at various times. In some cases, it instantly follows 
the original stimulation, and increases in frequency, the intervals between 
the separate contractions decreasing, and the muscular movements in- 
creasing in violence. 

In one patient at present under observation, the initial tap causes at 
first an immediate but not very violent kich. This is followed by others 
which increase in the frequency of their appearance seemingly as if every 
muscular contraction arouses new collections of nerve force and promotes 
the escape of nervous discharges, until finally as the irritability of the cen- 
tral apparatus becomes exhausted, the contractions grow weaker and ulti- 
mately cease. In some cases the simple passage of the finger over the 
skin of the foot will give rise to the epileptoid tremor, and Joffroy^ has 



Method of Provoking Dorsal Clonus. 

(GOWERS.) 



^ Gazette Medicale de Paris, 1875, Nos. 33-35. 



DISEASES OF THE LATERAL COLUMNS OF THE SPINAL CORD. 351 

repeatedly produced the trepidation by the application of such gentle 
excitants to the skin as the contact of a finger-tip or a damp compress. 

Grasset ^ reminds us that when the patient is under emotional 
excitement, or when he makes an effort to execute certain move- 
ments ; or, again, when embarrassed at meeting a strange person, clonic 
spasms are sometimes spontaneously produced. 

A variety of clonus, called by the French " trepidation spontanee," 
takes place when no apparently affecting stimulation is used. The move- 
ments of a tremulous character which agitate the lower extremities of a 
healthy person, who is fatigued after a long walk, or some such effort, is 
but a simple illustration of the condition of affairs which exists in dis- 
ease of the lateral columns, in a more pronounced degree. A constrained 
position, or one in which the tendons are slightly stretched, is highly fa- 
vorable to the causation of a paroxysm of tremor, and where the central 
irritability is great, the mere contact of the clothing is oftentimes all that 
is required as a peripheral irritation. The recumbent position and rest 
seem to modify the violence and frequency of these phenomena ; for it 
is only in exceptional instances that they occur during sleep. As soon, 
however, as the feet come in contact with the ground, the retraction of 
the heel takes place, and every step in walking is connected with more or 
less spasmodic movement. 

A form of reflex trouble which has received but little notice, is the 
abdominal reflex. This I have noticed in lateral disease, and I think it 
should be considered always as a pathognomonic sign of the affection. 
When the finger is passed ever so slightly over the abdominal parietes, 
there will be a peculiar, almost vermicular contraction of the underlying 
muscles. I have never seen this sign absent in spasmodic spinal paralysis. 
This excitable condition of the abdominal muscles has probably some- 
thing to do with the curious action of the bladder ; and it is probable that 
the muscular fibres of this organ are also subject to reflex spasm which 
results in the forcible and spasmodic discharge of the urine which some- 
times occurs. 

In certain cases the action of the will is capable of modifying, if not 
stopping, disorderly movements of a reflex nature ; but in the great ma- 
jority the reverse is the rule, and the attempted exercise of the volition is 
frequently all that is required to increase the movements. 

In one case I have witnessed a phenomenon which is not uncommon in 
connection with the transmission of peripheral painful impressions — I al- 
lude to delayed conduction. In this case the tap was not immediately 
followed by contraction ; but from three to five seconds elapsed before 
any movement was to be observed 

In pure uncomplicated disease of the posterior part of the lateral col- 
umns there should be no muscular atrophy. In varieties beginning with 
disease of other parts, or injury, such a condition of affairs is possible but 
not commonly seen. Any loss of muscular substance is simply due to 

^ Maladies du Syst., n., Paris, 1878, p. 375. 



352 DISEASES OF THE SPINAL CORD. 

inaction of the limbs, and is of peripheral origin, and involves the entire 
limb. Bed-sores are not a feature of the paraplegia, at least not until the 
other parts of the cord become involved ; but in the early form of what 
may be a secondary local affection they are sometimes seen, as was the 
case in two or three of Seguin's patients. In the latter stage of primary 
disease they do occur and have been occasionally observed. In no cases 
have I observed skin diseases, arthropathies, or other indications of defective 
nutrition. In the confirmed and advanced examples of the disease, a 
mottled or bluish appearance of the extremities (such as is witnessed in 
pseudo hypertrophic and infantile paralysis), is quite common Tnis is 
more noticeable when the patient's clothing is removed and the skin 
exposed to the air, when the pink blush appearing at first gradually 
assumes a, dusky hue. 

Although all authorities deny the existence of any form of sensory 
alteration, they nevertheless prove by their published cases that in the ear- 
liest and last stage of disease of this part of the spinal cord, various sensory 
phenomena are presented. For instance, in seven out of twelve cases of 
primary disease of the lateral columns, there were either pains, anaesthe- 
sia, or light forms of surface hypersesthesia. " Tingling," or " burning " 
sensations, dragging pains, " pricking," or " numbness " are spoken of, 
and probably arise from some irritation of the posterior nerve roots. 

It may be stated positively that absence of anything like sensory dis- 
turbances, such as are found in other spinal diseases, is the rule ; but it 
cannot be denied that an occasional or early diminution, or more com- 
monly, elevation of the cutaneous sensation, is a feature of affections of 
this kind. 

In the secondary disorders, where perhaps a congestion of the posterior 
columns is the primary marked process, or where pressure is made by 
some growth, or, by a diseased vertebra, or, as is sometimes the case, by 
the products of inflammation in meningitis, there must be more or less dis- 
turbance of sensation. In special varieties this is decided, and where 
associated with hysteria it is not unreasonable to expect to find anaesthe- 
sia; but unlike the impaired sensation in true spinal disease, it is irregu- 
larly distributed, and often associated with ovarian hyperaesthesia. 

In one of the cases reported by Seguin there was anaesthesia, probably 
the result of injury of nerve tracts other than the lateral columns, but as 
in other cases the symptoms of literal disturbances predominated. 

Tactile sensibility seems to be in no way affected ; and appreciation of 
heat and cold are usually normal, except in advanced stages, when sub- 
jective cold is complained of. 

There are never any indications of paresis of the bladder or rectum. 
Constipation is not usual; and if there is any bladder trouble it is one 
of a sthenic nature, and accompanied by spasmodic ejection of the urine. 

The patient is quite able to stand with his eyes closed, before his loss 
of power renders him helpless — and he can co-ordinate properly. The 
only exception to this rule is when the disease has involved the posterior 
columns, as in the complicated cases mentioned by Erb. 



DISEASES OF THE LATERAL COLUMNS OF THE SPINAL CORD. 353 

I. 

CONGENITAL IMPERFECT DEVELOPMENT OF, OR DEGENERATION OP THE 

LATERAL COLUMNS OF THE SPINAL CORD. INFANTILE 

FORM, "SPASTISCHE SPINALLAHMUNG BIE 

KLEINEN KINDERN" OF ErB. 

The subject of spasmodic spinal paralysis of infancy has received but 
passing notice, and a contribution of Erb's^ is the only description 
to be found of the. disease which is an analogue of adult spastic 
paralysis of the primary form. Four cases were presented by this 
observer, two of which were described in his second article^ in Virchow's 
Archives ; and two others are detailed in the communication before re- 
ferred to. 

I have seen several cases which are clearly marked examples of spastic 
infantile paraplegia. Several of these cases have also been observed by 
others, but not recognized and described as lateral column disease, and 
in more than one case the disease has been regarded as the result of 
preputial irritation from phimosis. 

The paresis is usually not recognized until a year or so after birth, 
when the child should walk, but does not do so ; and in such cases the 
ailment, as Erb has pointed out, has too often been mistaken for infantile 
palsy or some such common disease of early infancy. If this error is not 
made, ante-natal cerebral hemorrhage or spinal traumatism is generally 
supposed to account for the paralysis. One-sided brain atrophy, such as 
has been alluded to by Taylor,^ produces a hemiplegic condition with 
contractures, exalted tendon-reflex, etc. ; but cerebral symptoms of 
greater or less importance are added thereto. 

Finally, it has been the fashion of late to ascribe all the trouble to an 
irritated and phimosed prepuce. Circumcision has even been tried in 
many instances ; but the rigidity and paresis have remained the same, 
for in all of these cases, the trouble was far beyond the surgeon's knife. 

In this form of disease, or congenital partial absence of the lateral col- 
umns, the contractures, according to Erb, make their appearance at a 
very early age. In one of the patients I have seen, the limbs are as 
rigid at the age of seven, as they would be in the advanced stage of 
this disease in an adult ; and in such a condition, I understand, they have 
been since the third year. 

This early development of contractures is ascribed by Erb to the im- 
perfect voluntary power which belongs to childhood, which prevents the 
little patients from exercising or resisting the advance of the deformity. 

Subjective coldness is noticed, and the cutaneous circulation is sluggish, 
so that the limbs have a mottled appearance. The ability to speak 
seems to be impaired — not from a condition of mental weakness, however, 
for the mind of many of these children is quite active ; but there appears 
to be both a local awkwardness and a disinclination to talk. Unless the 

Op. cit. 2 Virchow's Archiv., B. 70, 1877, p. 293. ^ Q.^y^ jjosp. Eep., 1878- 
23 



354 DISEASES OP THE SPINAL CORD. 

patient is held upright, he is quite unable to walk alone, for there is 
crossing of the legs, and adduction of the thighs. If a determined 
effort is made to walk (he being supported meanwhile), the feet will 
be drawn into the position of talipes, and his toes will catch thb ground 
at every step. The disposition is for the feet to be drawn across each 
other, so that in an extended position, one foot covers its fellow, and so 
they remain. When laid upon the bed the legs and thigh are sometimes 
drawn up and agitated by clonic movements. In severe cases the loss 
of power is so great that (as in adult cases) the patient cannot lift his 
feet or raise his legs. 

No sensory disturbances are complained of; and in but one of Erb's cases 
was there any symptom of this kind, and that a slight hypersesthesia. Skin 
and tendon reflexes are increased. Bladder and sphincter ani, normal. 
Cerebral symptoms, nil. 

A curious fact appears to be established, — and this is, that in three of 
the seven cases I have collected, the children were prematurely born ; 
and I think great importance of a pathological kind must be attached to 
such a state of affairs. 



II. 



PUNCTIONAL DISEASE OP THE LATERAL COLUMNS. 

The recently reported case seen by Kussmaul ^ is an example of this 
kind ; for the favorable results obtained by him were highly suggestive 
of such a conclusion. Berger^ has also seen a case; and I have no 
doubt but that many of the cases of spasmodic troubles of the lower ex- 
tremities, known heretofore as " functional spasms," are after all only 
varieties of ischsemia of the lateral columns. 

In Hanfield Jones' work,^ I find reference to a case reported by Baum- 
berger, which is as follows : — 

The patient was a youth, 19 years of age, who during convalescence 
from pneumonia, began to suffer with a spasmodic afifection of the lower 
extremities. " As soon as he touched the ground with his feet, all the 
muscles of the lower extremities fell into a state of tetanic rigidity, inter- 
rupted by the most violent, sudden contractions, which threw the patient 
upwards ; and during their rapid recurrence increased in intensity, so 
that the patient had to be supported. At the same time, the face was 
flushed and distorted, the pulse accelerated and extremely feeble. The 
moment that the patient sat or laid down, all the movements ceased. If, 
while lying in bed, the soles of his feet were pressed, the same phenomena 



1 Berliner Klin., Wochenschrift, Sept. 23, 1877. 

2 Abst. in Centralblatt, July 13, 1878 . 

^ Schmidt's Jahrsbericht, vol. cij., pp. 23-4, and H, Jones on Functional Nervous 
Disorders, p. 398. 



DISEASES OF THE LATERAL COLUMNS OF THE SPINAL CORD. 355 

appeared, but with much less intensity." He was cured by sedatives and 
cold affusions. 

In the interesting case reported by Kussmaul, complete recovery took 
place within less than one year. 

III. 

HYSTERICAL SPASMODIC SPINAL PARALYSIS. 

The celebrated case reported by Charcot of hysteria, in which the four 
extremities were contracted, is one which illustrates a form of disease of the 
lateral columns occurring as an outgrowth of the neurosis which is so 
commonly thought to be a purely functional affection. This and other 
cases are so well marked, however, and present such unmistakable symp- 
toms of both diseases that I think a hysterical variety of spasmodic spinal 
paralysis may be recognized. 

In all of the cases to which I shall refer, it is probable that the primary 
disease was purely peripheral, and as a central degeneration has been 
known to occur after section of important nerve trunks there is no reason 
why we should not with perfect reason recognize the same pathologi- 
cal origin in cases where long existing hysterical paralysis has 
been connected with a more than ordinary inactivity and disuse of a 
member.^ 

Charcot, in his early fasciculus, (1872-3), goes quite extensively into the 
question and describes the " tremulation convulsive," and other symp- 
toms. He says: '^Quelle condition est done survenue et a entretenu 
ainsi I'existence de cette paraplegie avec rigidite des membres ? Evidem- 
ment, dans les cas rdcents de contracture hyst^rique, la modification or- 
ganique, quelle quelle soit, quel que si^ge qu'elle occupe, qui produit la 
rigidite permanente, est tres-legere, tres-fugace puisque les symptomes qui 
lui correspondent peuvent disparaitre tout-a-coup, sans transition, * * * * 
il s'est produit, a une certaine epoque, une lesion scl^reuse des cordons 
lateraux, lesion que la ndcroscopie permettrait actuellement de recon- 
naitre." 

Briquet has seen cases of paraplegia complicated with contractures, 
and mentions three examples. In these cases there was pain and rigidity, 
especially when passive movements were attempted. One of his cases 
afterwards fell into Charcot's hands, and is that of which we have 
spoken. 

The development of symptoms indicative of lateral column disease is 
rarely an early feature, and in the reported cases there was a primary 
hysterical paralysis which had lasted some years, when the first indica- 
tions of the degeneration of the lateral columns were shown in an in- 
crease in all the reflexes, and an increase of the rigidity of the contrac- 
tured limbs. 

1 Traite clinique et therapeutique de 1' hysterie. Paris, 1859. 



356 DISEASES OF THE SPINAL COED. 

In more than one of Richter's^ cases there was a decided hysterical 
element, but this was not exhibited before the more important special 
symptoms had shown themselves. 

IV. 

PEIMAHY DEGENERATION OF THE LATERAL COLUMNS. 

(^Tabes Dorsalis Spa^modique, Spasmodic Spinal Paralysis, Lateral Spinal 
Paralysis.) Tetanoid Paraplegia {Seguin). 

The disease which by Charcot has been supposed to be essentially a 
sclerosis of the lateral columns of the spinal cord, though in such a con- 
clusion he has not been supported by Erb, has been called by the former 
"Tabes dorsalis spasmodique," — and by Erb, "spasmodic spinal par- 
alysis." 

With the exception of the few infantile cases already referred to, 
which I do not believe to be always identical with those in which the 
disease begios later in life, so far as pathology is concerned, the reported 
cases have all been among adults. In the cases so far observed, the 
beginning of the disease has been singularly slow and insidious. There 
has been no febrile stage, and absolutely none of the early and sudden 
symptoms which attend the development of many of the spinal paralytic 
diseases ; but, on the contrary, the appearance of symptoms has been 
very gradual. 

In most of the cases brought forward, there have been initial 
symptoms of a sensory character, although few of them have been more 
than irregular and fugitive. Dragging pains in the hips and down the 
back of the thighs, pain in the back, and sometimes hypersesthesia of no 
very lasting or severe kind, enter the list. 

In Erb's^ cases (16 in number), seven presented sensory symptoms 
in the first stage. In six the pain was, without doubt, due to spinal irri- 
tation ; and in the other cases there was a doubt in favor of articular 
rheumatism. There were various transitory and ill-defined pains, formi- 
cations in the fingers and soles, and subjective cold. In Schulz's^ paper, 
other cases with such initial symptoms are mentioned. Charcot, ^ how- 
ever, does not believe in the existence of pains during the first stage, and 
a few other authors agree with him ; but in the German and American 
examples of this disease, so far reported, there is ample reason to believe 
in their existence in about one-half of the number of cases. These 
sensory troubles usually last for a few months, and may be coincident 
with the appearance of muscular weakness, such as has been described 
under another head. 



1 Deutsclies Archiv. fur Klin, Med. 18, 6, p. 365. 

^ Virchow's Archiv., Bd. Ixx., H. 2, page 24, et seq. 

^ Archiv. der Heilkunde, 1877, page 352. 

* Legons sur les Malad. du syst., N. 4"^®' fascic, page 279. 



DISEASES OF THE LATERAL COLUMNS OF THE SPINAL CORD. 357 

Patients wlio are in the advanced stage of the disease present in addi- 
tion to great loss of power, contractures of advanced development ; and, 
as a consequence, there is deformity which is always quite prominent. 

As to the loss of power, it will be noticed that in nearly all the reported 
cases the lower extremities were affected in the beginning, although it 
is not rare to find either hemiplegic cases, or those beginning on one side 
and afterward involving the other, this extension occupying a long 
period of time. Again, the upper extremities are sometimes affected first ; 
but these cases are extremely rare, and I can find but two mentioned. It 



Fig. 54. 




Contraction of feet in an advanced case of primary degeneration of the Lateral Columns. 

however follows that when loss of power begins below, the arms are 
quite likely to be affected ; so that the contractures, trepidations, and 
all the symptoms already shown below are likely to appear in the upper 
extremities after two or three years. Even the muscles of the trunk, as 
shown in one of my cases, are finally implicated. 

Betous makes the third stage of the disease include general contrac- 
tures of the upper and lower extremities and trunk muscles. The loss of 
power can hardly be called an absolute paralysis, for the paresis is un- 
equal, and the patient possesses for a long time a great deal of ability to 
perform certain actions with a great deal of ease, while others are 
impossible. 

Motor irritation is a feature of the second stage of the disease, and ac- 
companies the paresis. The first indication of stiffness marks the appear- 
ance of this symptom, and a variety of irregular disorders of motility 
follow, such as twitching of the feet, tremor amounting almost to 
clonic spasms when the toes are allowed to touch the floor, and rigidity, 
when passive movements are made, then other phases of excitement in 
muscular action are exhibited in different degrees, and at different times 
until the disease has run an extended course. I have found that 
in some old cases the clonic movements following excitation are not so 
active as in the early stages, but that spastic rigidity, and contractures 
apparently uninfluenced by any ordinary excitation, exist ; and also that 
there is no apparent increase of rigidity in connection with the excita- 
tion of any special movements. 

As to the negative symptoms of the disease, there is little to be added 



358 DISEASES OF THE SPINAL CORD. 

more than what has been stated in speaking of general symptomatology. 
It may be said, however, that there is no impairment of the sexual 
powers. 

The disease ultimately reaches a stationary period ; and unless there 
be a subsequent acute myelitis which ascends and involves the bulb, the 
patient is likely to live for years, finally to die from an intercurrent 
disease. After the stationary period is reached he is perhaps helpless, and 
is confined to his bed. His contractures may become painful, and in gene- 
ral his health suffers through inaction and want of exercise. 

In some cases the attempt to stand is attended with great sufiering, as 
the toes are flexed ; and when the entire weight of the body is thrown on 
them in this constrained position, the patient is often unable to progress 
even with the aid of a stick or crutches without great agony. 

I have noticed, in connection with the other symptoms in two of my 
cases, a great deal of emotional disturbance, which at times amounted 
to hysteria ; and I am inclined to believe that this is but another illustra- 
tion of the appearance of sysmptomatic hysteria in connection with 
organic nervous disorders, such as has been clearly described by Charcot, 
S^guin and others. 

Causes. — The causes of disease of the lateral columns are but little 
known, if we may put out of the question such mechanical factors as ex- 
ternal disease or pressure, such as are found in secondary degeneration. 

A reference to some of the forms of trouble spoken of in other pages is 
all that may be necessary under this head (I allude to the hysterical and 
infantile forms). In the first, I think there can be no doubt as to the 
origin of the affection as its name implies ; while in the other there are 
actual cavities in the cord ; degeneration with syringo-myelia or non- 
closure of the central canal; or imperfect formation of the lateral 
columns. 

In such cases, there seem to be no hereditary influences to explain 
their origin except perhaps consanguineous marriages ; and we arrive 
at about the same result when we attempt to trace back influence 
of this kind in cases of cleft-palate, hair-lip, and congenital deformities of 
other kinds. 

In one of Erb's cases occurriug in infancy, the fact that five other 
children in the same family were born before full term, is suggestive of a 
tendency to non-development. In Kichter's four adult cases, there was a 
history of insanity on the father's side in two cases, and sclerosis in a 
third. 

An infantile case is reported by Berger, in which the disease followed 
an attack of diphtheria ; but this is the only infantile or adult case in 
which I can find such a complication, except one, a man who had scarlet 
fever in early life, which was the beginning of his serious trouble. The 
lateral columns of the spinal cord are rarely the seat of primary dis- 
ease until after the twentieth year, — although Erb has reported the 
disease in a girl of sixteen. In hysterical cases, even, the primary 
paresis and contractures rarely appear before several years of hys- 



DISEASES OF THE LATERAL COLUMNS OF THE SPIXAL COED. 



359 



terical paralysis have passed. In one of my cases the disease was estab- 
lished at twenty-two ; and in none of Charcot's cases did the affection 
appear before adult life. In secondary disease, there is no regularity in 
the question of age. I think in the extra-spinal form, childhood is the 
period when we may expect the causation of such troubles ; while if there 
be tumors, effusions of blood, or meningeal disease, there can be no in- 
fluence referred to age. 

The ages of all the patients with primary disease (spasmodic tabes), 
whose histories I can gain access to, are the following : — 



Between 15 and 20 ... . 


... 2 


Between 40 and 50 . . . . 


... 9 


" 20 " 30. . . . 


... 8 


" 50 " 60 ... . 


... 3 


'' 30 - 40. . . . 


. . , 15 




— 



As to the occupation of these patients, — 



Total . 



37 



3 . 


. . were . 


. laborers. 




. . was a . 


. . shoemaker 


2 . 


. . were . 


. peasants. 




ic 


. . painter. 


2 . 


. . were . 


. tradesmen. 




i( 


. . printer. 


1 . 


. . was a ., 


. barber. 




" 


. butcher. 


1 . 


. . was a . 


. . teacher. 




a 


. . carpenter. 


1 . 


. . was a . 


. car-driver. 




. was a . 


. . clerk. 


1 . 


. . was a . 


. . silversmith. 









and in twenty cases the occupation was not stated. 

Of these patients 22 were men, and 15 women. In fact, the disease is 
not so common among women, and in many of the cases there was an 
hysterical element, notably so in the case of the Princess F., reported by 
Erb. In one of his articles he refers to the fact that the disproportion in 
sex is not so great as in locomotor ataxia. Climatic influence has been 
alluded to : in fact the singular circumstance that a number of Erb's cases 
were from Rheinish Bavaria led him to think that there was some 
endemic influence ; but the subsequent recognition of cases in all parts 
of the world proves the contrary. 

In one case reported by Betous and another by myself, the patients 
were metal workers ; but at least in one of these cases there were other 
causes; so the theory of metallic poisoning must fall to the ground. 
Syphilis has not entered into the history of the cases; and Erb 
does not think it has much influence in the production of the 
disease. " Damp, humid cold," in the experience of Charcot, who has 
seen five cases, has existed as a cause ; and in many cases, exposure 
to rain, excessive venery or dissipation have played parts in the 
development of the disease. So little is known in regard to the 
genesis of all forms of sclerosis, that any attempt to solve the problem 
must be speculative. I believe that locomotor ataxia (and probably 
the disease in question) is undoubtedly due to what is at first but an 
ischsemic spinal state. In certain individuals of sedentary habits and 



360 



DISEASES OF THE SPINAL CORD. 



nervous temperament, occasionally the victims of the gouty vice, the 
cord is subject to sudden modifications in circulation, and consequently 
in nourishment, and as a result a condition of " spinal irritation " in the 
primary trouble which may depend upon anaemia on the one hand, or 
unequal congestion on the other ; and as a result of such changes a hyper- 
trophy of the conuective tissue follows, which constitues the sclerosis. 

Pathology and Morbid Anatomy. — The proper discussion 
of the genesis of congenital spastic paralysis would involve an extended 
consideration of the development of the spinal cord, which would be out 
of place in a text book. The existence of anomalies in the cord, such as 
have been described by Ollivier, Longet, Goll, Calmeil, Charcot, Leyden 
and others^ under the head of Syringo-myelia and hydromelia will explain 
development of early disease of the lateral columns. Leyden'' has minutely 
described the openings found especially in the posterior columns as the 
result of myelitis. 

In Leyden's cases the cavicies which were the result of disease during 
foetal life were characterized by great unevenness of contour, by splitting 
up of the opening into others, or bye ertain indefinite and irregular varia- 
tions, while the canals due to the absence of tissue incident to arrest of 
development were of symmetrical configuration ; and the cord rarely pre- 
sented any evidence of general disease, such for instance as sclerosis. 

As to the arrest of development of the cord and the consequent abnor- 
mality in the lateral column function, we must take into account the fact 
of the existence of the transverse fissure alluded to by Charcot and others, 
among them Waldeyer. It is probable that the infantile forms of lateral 
column disease therefore are due either to some imperfect closure of the 
lateral column or a sclerosis beginning during uterine life. 

Fig. 35. 




(Leyden.) 



1. Syringomyelia. 2. 3. Hydromyelia. a. a. Lateral fissures and imperfect development of 
lateral columns. 

Flechsig,^ in an elaborate article, has written extensively upon the con- 
nection of certain fibers in the lateral columns, with cells in the anterior 



1 See Prize Essay of American Medical Association upon Primary and Secondary 
degeneration of the Lateral Columns of the Spinal Cord, 1879, by the author. 

2 Virchow's Archives, Bd. 68, Oct. 9, 1876. 

3 Archiv. der Heilkunde, 1877-1878. 



DISEASES OF THE LATERAL COLUMNS OF THE SPINAL CORD. 361 

gray horns and Clarke's columns and certain fibers of the crossed pyra- 
midal columns evidently arise from large cells in the anterior parts of 
the anterior horns, and these are supposed by him to be concerned in the 
provision of peripheral motor power, and to be involved when there are 
contractures. Fig. 56 will enable the reader more fully to study his ar- 
rangement. 

(Fig. 56.) 




(Flechsig.) 

T. C. Column of Tiirek. C. G. Column of Goll. C. L. Clarke's column. 1. Fibers in 
cerebellar column connecting with Clarke's column. 2. Connection of crossed pyramidal fibers 
with gray matter. 3. 3. Connection of fibers of anterior column with cells of anterior cornua. 

Gray^ says that he is not prepared to accept Flechsig's views in their 
entirety, because he believes that disease of the crossed pyramidal columns 
is not always associated with contractures, and brings forward a case re- 
ported by Shaw in refutation in which the morbid processes involved the 
crossed pyramidal columns, and still this symptom did not occur 

The numerous cases of secondary degeneration after cerebral disease, 
in which contractures of the most formidable and conspicuous kind were 
manifested, and in which all degrees of degeneration, partial and com- 
plete were observed, would, however, rather neutralize the value of a 
single exceptional case ; and such have been frequently reported. 

The experiments of Woroschiloff ^ on animals have shown that the 
lateral columns of the cord contain motor and sensory fibers, which are 



^ Transactions of Kings Co. Medical Society. 

^ Ludwig's Arbeiten, 1875. Abstract in Journal of X. and M. Diseases. 



362 DISEASES OF THE SPINAL CORD. 

variously distributed, and for the anterior part of the body the action of 
the latter is crossed, this action being more perfect in the fibers of the 
middle third of the lateral columns. There are also motor fibers in this 
part of the cord. His experiments show that irritation of the peripheral 
sensory nerves of the limb of an animal in front of the lesion of the cord, 
produces only reflex movements in the limb on one side, which is wholly 
or in part uninjured. If, however, this part of the lateral column 
is destroyed, it is impossible to cause reflex movements in the hind 
limb, even when excitation of the anterior part of the body is severe. 
It was found that if the anterior half of the lateral columns was not 
intact, no reflex movements could possibly be induced. Electrical exci- 
tation of the cervical cord " caused repeated alternate flexion or exten- 
sion, or tetanic contraction of the limbs." The first would not follow if 
the middle third of the lateral columns was not intact. The clonic con- 
tractions took place even when the corresponding lateral column was de- 
stroyed. In regard to the production of the tendon-reflex, Schultz ^ and Fu- 
erbringer have experimented by dividing the cords of rabbits and exposing 
the tendons. They have come to the conclusion that the phenomena of 
tendon reflex are not those which result from a local excitation through 
muscles, nor that such movements are skin reflexes, but that there is local 
irritation of certain nerves described by Sachs,^ which have terminal fila- 
ments in the tendons. We are also reminded by Erb,^ that the tendon 
reflex occurs even when the tendon is tapped in situations where there 
is underlying bone, and where there is no possibility of jar or mechanical 
irritation of the attached muscles. The tendon in a relaxed condition 
can even be pinched when held in the fingers, and contraction will 
follow. 

To do away with the possibility of cutaneous irritation, the skin may 
be ansesthetized by the local spray, and the same thing then occurs. 

In some of Erb's cases, the tendon-reflex could be excited by pressure 
over one of the lumbar vertebrae, or over other bony prominences ; but 
in this case there was no secondary reflex. " In examples where irritation 
of the skin gives rise to the tendinous movement, the same are likewise 
secondary. 

It has also been found that pressure on the central nerve will diminish, 
if not stop, the various expressions of heightened reflex in the lower ex- 
tremities. The different phenomena of the tendinous reflex depend upon 
the integrity not only of sensory nerves, but the paths of sensory con- 
dition in the posterior columns; and Henz* observes that in certain 
hemiplegise connected with hemi-an^esthesia, the probable failure in pro- 
ducing tendinous and other reflexes depends not so much upon the paresis 
of the muscle, as upon the insensibility of the integument, or the nerves of 

1 Centralblatt f. d. Med. Wiss., No. 54, 1875. 

2 Eeichert and Du Bois Keymond's Arcliiv. iv., 1875, p. 402. 
^ Ziemssen's Cyclop., vol. xiii., p. 49. 

^ St. Petersburg Med. Wochenschrift, No. 35, Oct. 30, 1876. 



DISEASES OF THE LATERAL COLUMNS OF THE SPINAL CORD. 363 

the sinews. The central conditions which enter into the production of 
exaggerated states of the tendinous reflex, and of the reflex disorders 
of motility, are — 

1st. A condition of irritation or inflammation of the central gray sub- 
stance ; 

2nd. A suspension of inhibition.^ 

In this case the lesions involve the strands of nervous conducting mat- 
ter concerned in the transmission of cerebral or local inhibition. 

In the diseases under discussion, it would appear that the last of these 
is that which enters into the pathology of diseases of the lateral columns ; 
for in the majority of cases the gray matter is intact. 

The careful investigations of Flechsig, already referred to, demon- 
strate that certain fibers in the lateral columns are connected with certain 
cells in the anterior cornua and other parts ; and that in disease afiecting 
this part of the cord, the spinal inhibitory action which is acknowledged 
by nearly all neuro-physiologists, among them Erb,^ Brunton,^ and others, 
to enter into the production of certain motor impulses of spinal origin, is 
suspended. 

Allusion has been made, in speaking of symptomatology, to the fact 
that an original excitation of a tendon was often followed by a series of 
muscular contractions. 

This has been noticed by Freusberg; and according to Pfleuger* it is 
explained by the theory that the original excitation is transformed from 
sensory to a motor fiber on the same side of the cord ; and then by 
others on the other side ; thence back, following a zigzag course and 
giving rise to unequal muscular motorial innervation, and this will also 
explain the occurrence of transmitted reflexes to the other side of 
the body. 

The contractions which occur are due to a 'tonic rigidity of the 
flexors and are rarely if ever attended by any change of substance or 
tissue of the muscle, but are due to an irritation of central nervous 
tracts. 

The spastic gait is the result of reflex contraction of the muscles, de- 
pendent upon retractions of the tendons ; and with this a certain 
paresis. The early sensory disturbances are due probably to irritation of 
the posterior nerve-roots, or perhaps to parts of the lateral columns which 
have been found by Ludwig and others to be concerned in the transmis- 
sion of sensory impressions ; and, as a consequence, the dragging neural- 
gic pains and burning. 

1 In regard to the suspension of cerebral inhibition, I think we may make use of 
the hysterical cases of lateral column degeneration to explain how an inveterate 
voluntary paralysis, such as occurs in hysteria, may by a continuous arrest of inhibi- 
tion of the central variety, lead to a degeneration of parts concerned in the trans- 
mission of voluntary impressions. 

2 Op. cit. 

' West Eiding Eeports, vol. iv. 

* Quoted by Erb. 



364 DISEASES OF THE SPINAL CORD. 

The gross appearances of disease of the lateral columns present many 
variations ; and markedly differ in regard to situation and degree of de- 
generation. It is unusual to find absolute non-involvement of the other 
columns of the cord, as in the case observed by Westphal, and alluded 
to by Erb. The posterior columns are liable to be affected to some ex- 
tent ; and this complication affects very slightly the clinical features of 
this disease ; while if there be involvement of the anterior columns, 
the conspicuous atrophy will give to the disease picture a very 
different aspect. This condition of affairs was witnessed in a case of 
anomalous progressive atrophy brought forward recently by Shaw,^ 
and there are additional cases of this character reported by French 
authors. 

So far, no autopsies have been made which revealed uncomplicated 
disease. 

In a case which has been diagnosed by Charcot^ to be one of pure 
" Tabes dorsalis spasmodique," the disease of the cord came more prop- 
erly under the head of disseminated sclerosis than local degeneration. 
This case is mentioned in Betou's thesis. Ollivier gives autopsical re- 
sults, but these are too indefinitely detailed, and too inexact to be of 
much service. The cases, however, which are of greatest interest to us, 
are those in which there has been secondary disease. It has been 
assumed by Charcot, and in some of his hysterical cases it has been 
found, that the form of degeneration known as " primary " occupies a 
wedge-shaped area beginning at the cord, and extending through both 
the cerebellar and crossed pyramidal columns. 

In one of his cases ^ the sclerosis was found to involve the entire length 
of both lateral columns, while other parts were perfectly healthy. There 
was no trace of meningitis, and the character of the semi-gelatinous, 
grayish change, was unmistakably sclerosis. The microscope revealed 
atrophy and disappearance of nerve tubes with annular constrictions. 
The gray matter was intact and the cells unaffected. There was in- 
crease of connective tissue and an abundant deposit of amyloid cells. 
In the descending secondary degeneration consecutive to cerebral dis- 
ease, the lesion will be found on one side only, and the crossed pyramidal 
fibres will be affected ; while if this descending form be seen as the 
result of spinal disease, the lesion will be bi-lateral and may involve other 
parts as well in the lateral columns at a different place. 

An ascending lesion, according to Erb,* Pitres,^ and others, is usually 
characterized by degeneration of a narrow peripheral border of tissue 
confined to the cortex and extending forwards somewhat as far as the an- 
terior nerve-root tracts. 

^ Journal of Mental and Nervous Diseases, January, 1879. 
•^Lepons, etc., 1878, p. 294. 

3 Gaz. Hebdom., No. 7, 1865, p. 109. 

4 Op. cit. vol. xiii., p. 773. 

5 Gaz. Med. de Paris, 1877. 



DISEASES OF THE LATERAL COLUMNS OF THE SPINAL COED. 365 

I have already sufficiently alluded to anomalies in development of the 
cord and the destruction of certain parts by disease before birth. Under 
this class comes the case detailed by Schultze/ in which, with hydrocepha- 
lus, there was congenital non-development of the spinal motor tracts and 
myelitis. Should the degeneration follow Pott's disease, Leyden ^ is of the 
opinion that it begins at the point of compression and extends down- 
wards, although Michaud has found in some cases of slow compression 
that myelitis ascends in these columns. Should the cortex be involved 
primarily, and be the seat of a myelitis, it will be found that there is 
thickening of the neuroglia, from the periphery to the centre, just as in 
the primary sclerosis. 

According to Lange, softening is a common form of degeneration, and 
the fibres of connective tissue are not uniformly thickened, but such in- 
crease of volume is detected here and there in the midst of the diseased 
mass, and irregularly-shaped nuclei will be found attached to their sides. 
In a case of my own, that of a girl who had died after suffering for some 
years from chronic myelitis (her limbs being contracted, especially the 
upper), it was found that the cord, especially in the cervical region, pre- 
sented evidences of lateral sclerosis, which were more marked on the 
right side. A transverse section of the cord at the cervical region, under 
a low power, presented the appearances depicted in Fig. 57.^ 

Microscopic examination revealed on both sides a hyperplasia of con- 
nective tissue, which was most dense at the periphery of the cord, while 
there was a compact network of fibres which interlaced and extended to 
the centre. While the thickening was perceptible in the anterior root- 
zone, it was especially marked in the posterior part of the lateral columns. 
With a low power, a dark triangular segment of dense connective tissue 
was observed extending from the periphery to the outer border of the cen- 
tral gray matter. Extending posteriorly to a point limited by an imagi- 
nary line drawn from the posterior group of ganglion cells in the tractus 
intermedio lateralis to the border of the cord internally (^. e. adjacent 
to the gray matter of the posterior horns), was found a reticulated ar- 
rangement of thickened fibres, the interspaces becoming smaller, and the 
neuroglia more dense, until within a short distance of the direct fibres of 
the cerebellar column. At this part the spaces become larger and elon- 
gated, and the fibers more prominent. In the anterior part of this dense 
tissue were found arterioles with thickened walls surrounded by granular 
substance which had been thrown out. In the spaces between the thick- 
ened <jonnective tissue, there was a general disappearance of nerve tubes, 
w^hich was most conspicuous towards the periphery, w^here in certain local- 
ities but two or three fibers could be detected. The axis cylinders in some 
places were swollen, and there was a scattered deposit of granular sub- 
stances, which was the result of " breaking down " of the connective tissue 

1 Centralblatt, No. 10, 1876. 

2 KHnik der Eiickenmarks krankeheiten, Erste Band. 

3 Abst. in Schmidt's Jahrsbericht, 168, 1875, p. 238. 



366 



DISEASES OF THE SPINAL CORD, 



cells. The ganglion cells of both anterior horns were seemingly unaffected 
and their nuclei were distinct. The columns of Goll were also found to 
be the seat of sclerosis. 

It is possible that in this affection there may be several grades of patho- 
logical trouble. 



Fig. 57. 




CL--A 



a. a. b, b. Sclerosed Tracts. 



In Lange's^ communication attention is directed to two conditions de- 
pendent upon varying degrees of diseased action : — 1. Simple gray colora- 
tion without any destruction of nerve tubes. With this there is a promi- 
nence of neuroglia cells, while there is an increased clearness of the nuclei. 
The general discoloration is darker than in the next form. 2. Sclerosis, in 
which the main element is increase of connective tissue, and destruction 
of nerve tubes. 

It is probable that these two conditions are those which are to be found 
in cases of slow progress, while a myelitis with softening is probably not 
uncommon in the secondary forms. 

The changes which begin in simple discoloration and extend to sclero- 
sis, include a list of slow changes of a progressive character. The nerve 
tubes appear at first altered in calibre and become swollen ; their axis 
cylinders also swell, and there is unequal bulging of the membranes, giv- 
ing rise to an appearance of varicosity. Granular degeneration is proba- 



Op. cit. 



DISEASES OF THE LATERAL COLUMNS OF THE SPINAL CORD. 367 

bly the next step in the process ; and ultimately there is shrinking of the 
nerve fibers and disappearance. In secondary cases the existence of 
myelitis in other parts is to be observed ; but the main appearance of 
the morbid process is to be localized. In many of these examples it is 
probable that the disease began by a simple ischsemic state, in some such 
pathological condition as the gray discoloration of Lange. 

Diagnosis. — The diagnosis of disease of the lateral columns of the 
spinal cord is usually unattended by many difficulties ; and the group of 
symptoms is too conspicuous and well-marked to permit the ob- 
server to err. Loss of power without atrophy, and reflex excita- 
bility without diminished sensibility enter into the formation of 
a unique train of symptoms; and unlike those of many spinal dis- 
eases, they are never separated in fully developed disease of this part 
of the cord. In speaking of the infantile form, I have alluded to 
several paralytic disorders of infancy with which it might be con- 
founded. I have been fortunate enough to see a case of double talipes, 
the result of infantile paralysis, which at first suggested the disease in 
question ; but even in this case the loss of electric muscular contractility 
(though there was not the extensive atrophy which might have been ex- 
pected), led me to make a diagnosis of that much more common form of 
infantile disorder — infantile paralysis. 

As to the primary disease of adult life, not much is to be said. It 
might possibly be mistaken for transverse myelitis, in which the urinary 
and vesical functions are involved, with bed-sores and anaesthesia. 
Locomotor ataxia cannot be mistaken for the disease ; for in certainly half 
if not more of the cases the patellar tendon-reflex is absent. There are, 
in addition, the symptoms of ataxia, loss of muscular sense, anaesthesia of 
the tactile variety, optic nerve disease, and visceral pains. 

The gait in the two diseases is radically difierent. In locomotor ataxia, 
the patient throws out his feet, coming down on his heels ; while in all 
forms of degeneration of the lateral columns, as has been shown, there is 
a tendency to walk on the toes — the feet seem to cling to the ground ; 
and there is adduction of the thighs. 

In disseminated sclerosis, there is usually tremor, irregular involve- 
ment of the extremities, cephalic disorders, and generally more or less 
ataxia. 

Chronic myelitis of the anterior columns, progressive muscular atrophy, 
and amyotrophic lateral sclerosis, may all resemble, in certain features, the 
disease under consideration — although if atrophy is conspicuous, the di- 
agnosis is easy enough ; but occasionally, an anomalous case is sufficiently 
puzzling to create a doubt. 

I have seen a case of progressive muscular atrophy of "the lower ex- 
tremities which presented exaggerated reflex excitement of the tendons. 
There was a general trepidation which could not possibly be mistaken for 
the unequal muscular contractions known as vermicular tremor ; but in 
this case there was a difference of an inch and a half in the circumfer- 
ence of the thigh, and the muscles of the neck were unevenly atrophied ; 



368 DISEASES OF THE SPINAL CORD. 

while added to the features of progressive muscular atrophy there was a 
commencing aphonia and other bulbar symptoms. 

In adult chronic spinal paralysis the development of the disease may be 
so insidious as to give rise to a reasonable suspicion as to its true nature ; 
and should there be added thereto slow contractions of the dorsal muscles, 
the diagnosis will be still more puzzling. In such cases the tendon-reflex 
will be found to be lowered or absent, and the contractures which result 
are not those of the spastic variety, but rather of paralyzed muscles op- 
posed to those which are not. 

The forms of secondary origin are more difficult to recognize ; for com- 
plicating symptoms play a part which greatly confuses the observer. 
There may be all the symptoms of unequal congestion, of myelitis, or of 
concussion of parts other than the lateral columns ; and time is required 
before it is possible to arrive at a conclusion. 

In such cases, the involvement of parts above the lesion is significant. 
A paraplegia of the lower extremities may exist and be connected with 
anaesthesia, retention and incontinence, and even bed-sores ; but at a later 
period, the arms may become the seat of paresis without ansesthesia, but 
with highly-developed tendon-reflex ; and at this stage it is possible to 
find diminution of the symptoms of an inferior transverse myelitis, the 
anaesthesia clearing away, the function of the bowels and bladder being 
restored, and the gait becoming changed ; while to the paresis there is 
added an excitement of the tendon-reflex ; but of course such cases are 
rare. Should there be anaesthesia, however, the case may be supposed to 
be one of central or posterior myelitis. The diagnosis of hysteria is some- 
times attended with difficulty ; but it may be borne in mind that the 
paralysis is one of a purely voluntary kind in the beginning. 

In this connection the reader is referred to an admirable article by 
Ferber and Gasser^ upon certain forms of contractures of the hands and 
fingers who report the case of E. Gull, a woman 39 years old, who had 
suffered for some time from irregular menstruation ; and for several years 
there had been periodic contractions of the hand and fingers. After- 
wards the hands became permanently contracted, there being spasms 
of the flexors without any atrophy whatever. The muscles con- 
tracted were the common flexors of the hands, as well as the adductors 
of the thumbs and interossei. Dr. Buzzard in a recent communication 
to the Lancet ^ speaks of the difficulty of diagnosing the cases of hys- 
terical origin from those of a purely organic character. 

Prognosis. — Infantile cases may be said to be utterly hopeless except 
when secondary to Pott's disease ; and neither medical or surgical treat- 
ment have so far proved of the least permanent benefit. 

•With cases of primary degeneration, or of the functional form, the 
matter is different. Erb has spoken of improvement ; and the cases 
brought forward by Kussmaul, Berger and others, show that the progno- 

^ Archiv. fiir Psycbiatrie, etc., vij., p. 140, 1877. 
London Lancet, June, 1881. 



DISEASES OF THE LATEKAL COLUMNS OF THE SPINAL CORD. 369 

sis is not utterly bad, and Nixon's case of antero-lateral sclerosis was 
greatly benefited by the remedies of which I have spoken. 

Hysterical cases are always rebellious, as the central disease is the con- 
sequence of a long existing nervous condition ; and not only is the psychi- 
cal influence difficult to combat, but the degeneration itself is of so ex- 
tensive a character that it defies successful treatment. Strange to say, 
secondary affections of spinal origin are not utterly beyond th^ reach of 
treatment. This is especially true in secondary degeneration or local 
disturbance after concussion. Erichsen ^ in his well-known work alludes 
to certain cases in which there was quite extensive spinal trouble from 
railroad injury with symptoms indicative of lateral column disease, and 
yet recovery took place. Should such concussion be unattended by 
laceration of nervous substance, there is some chance for improvement. 

Should there be extension upwards, as occurs sometimes in both the 
primary and secondary form of disease, there may be bulbar symptoms 
and death ; while if the cervical region of the cord be the district ulti- 
mately attacked, serious pulmonary symptoms may be added to those of 
the disease. 

Treatment : In the favorable case treated by Kussmaul, the chloride 
of gold and sodium in doses of gr. J t. i. d., was used until the patient had 
taken ninety grains in all. Erb places nitrate of silver at the head of 
the list of drugs, and at the same time recommends hydropathy. 

It would seem that ISTixon' also has found benefit to follow the use of 
the silver salt ; and much improvement followed in his case under the 
continued administration of the following prescription : 

R 

Argenti Nitratis, 

Ext. Nucis Vomicae, aa gr. jv. 

Ext. Gentiange, q. s. 

Tl\^ Divid in pill No. xii. 
Sig. One ter in die. 

Charcot is also in favor of the nitrate of silver, and suggests in addi- 
tion the application of the cautery along the spine. He has used the 
bromide of ammonium and sodium in large doses to diminish trepidation 
and spasms, and has met with excellent results. 

Faradism by means of the wire brush is recommended, and galvanism 
(the continuous current) has been of service in Erb's hands. Strychnine 
is advised against when there is so much reflex disturbance. Thermal 
saline spring baths have been praised ; but it has been found that inter- 
nally the waters do no good. 

In my own practice, I have found that the Fl. Ext. of Conium in 
doses of five minims thrice daily to be increased, is the best remedy to 
diminish the violence of the trepidation, while belladonna or the sulph. 

^ Concussion of the spine and nervous shock, etc. 
2 Dublin Monthly Journal, vol. Iviii., 1874, p. 207, 
24 



370 DISEASES OF THE SPINAL CORD. 

of atropia in local hypodermic injections of grs. ij, is useful when there 
is great spastic rigidity. Hyoscyamia acts well and is an admirable anti- 
spasmodic. 

As to other internal remedies, I have given phosphorus, the nitrate of 
silver, and chloride of gold a fair trial, but am disposed to place more 
reliance on cod-liver oil, ergot, or some salt of mercury for the treatment 
of the central disease, fully believiug that nutrition should be improved 
and the local circulation modified. 

I have found that the utmost quiet is necessary not only for the com- 
fort of the patient, but for the amelioration of the disease. He should 
be kept still, and not allowed to take fatiguing exercise ; and all sources 
of reflex excitation should be avoided. For the hysterical cases, we 
should pursue a different course and endeavor to make them bring into 
use the muscles of the affected limb. For cases of secondary origin, the 
galvanic current seems to possess great advantages; and should there 
be meningeal troubles, the administration of ergot is to be pushed. If the 
case be like one reported by Leyden, and probably rightly supposed 
by Erb to be of specific origin, it is necessary to give the iodide of 
potassium. 

TETANUS. 

Synonyms. — Rigor nervosus ; Mai de cerf ; Tetanos (Fr.) ; Locked 
jaw. , ^ ' , 

Definition. — Tetanus is an affection characterized by tonic spasms of 
a great number of muscles, particularly those of the jaw, neck, back, and 
lower extremities. It is never attended by loss of consciousness, and 
nearly always approaches an unfavorable termination. It is a disease 
which may be either idiopathic or traumatic, and is not confined to any 
age or sex, as it may be a condition at birth (trismus nascentium), or occur 
at any subsequent time. 

Symptoms. — The more familiar examples follow wounds, and such 
injuries may be exceedingly slight — the puncture of a rusty nail, a 
needle or a blunt instrument being often likely to give rise to the attack ; 
or it may be of distinctly idiopathic origin. The first symptoms- generally 
noticed are a stiffness of the neck, a slight soreness of the throat, and a 
contraction of the jaws so that it may be difficult for the patient to open 
his mouth. There may be general malaise and discomfort, which may 
last for several days, and the patient is unable to masticate or swallow his 
food properly, and consequently eats but little. He may think that he 
has simply caught cold, and neglect to seek medical advice ; but new 
developments will show the condition to be more serious than he ima- 
gines. 

The closure of the jaw may become more complete, and within the next 
twenty-four hours (the fourth or fifth day of the affection) he will show 
unmistakable signs of the increasing violence of the disease. His face 
wears the peculiar expression which has been called the risus sardonicus, 
the features appearing pinched and set, and the corners of the mouth are 



TETANUS. 371 

drawn upwards, while the eyes are prominent and the hair and eyebrows 
quite bristling. The brows are knit, and there is a characteristic appear- 
ance, which, if once seen, cannot be mistaken. Radcliffe considers the 
risus sardonieiis quite pathognomonic of tetanus. Pain in the epigas- 
trium becomes very severe, and is not relieved by medicine. It is impos- 
sible sometimes to open the jaws even when we desire to give food or 
medicine, and it is sometimes necessary to use quills and other delicate 
tubes for the purpose of feeding. Spasms of the pharyngeal muscles may 
also defeat all attempts of this kind, for, even if the teeth are parted and 
nourishment is inserted, the food is forced with great violence through 
the nostrils Other spasms now mark the progress of the disease. The 
muscles of the back begin to be convulsed, and finally those of the lower 
extremities, and as a consequence we observe the appearance of opisthoto- 
nos, which is an extremely striking symptom, and much more common 
than emprosthotonos, which may also take place, or pleurosthotonos. It is 
hardly necessary to say that opisthotonos is the result of a tonic spasm of 
the muscles of the back, so that the patient's body describes an arc, the 
head and heels touching the surface upon which he is lying, and the mid- 
dle of the back being raised some distance therefrom. When the body is 
bent in the opposite direction — forward — the condition is known as em- 
prosthotonos; and when the mus(4es upon one side of the body are con- 
tracted we designate the lateral curve produced as pleurosthotonos. Dur- 
ing this tonic convulsive state individual muscles may be the seat of 
painful spasms, which are very agonizing. Muscles have been torn 
across and bones broken by the great strain, and the force exerted is 
something wonderful. The tongue is rarely affected, and the hands are 
not usually at any time rigid or contracted. The spasms are easily pro- 
duced by slight agencies, as reflex irritability is decidedly exaggerated. 
Jarring the bed, tickling of the soles, or a draught of air allowed to blow 
upon the surface will immediately bring them on. This convulsive stage 
lasts until death, but when the end is approaching becomes less sthenic 
as the patient growls more and more exhausted. There may be an occa- 
sional severe paroxysm before death, but it is not at all like the form of 
violent convulsion of the middle stages. The pulse throughout the de- 
veloped disease is very rapid and fluttering and ranges between 120 and 
140, and the respiratory movements are irregular and catching, as the 
spasms affect the muscles of the thorax as well as others which are directly 
concerned in this process. Dyspnoea is very distressing, and is expressed 
between the seizures by much gasping and anxiety of countenance. The 
skin is dark, and large rings about the eyes are indicative of collapse, 
while the face of the victim is haggard and depressed. The patient 
perspires quite profusely, and the skin is excessively hot ; and a pro- 
minent feature of tetanus is the marked elevation of temperature, which 
rises even sometimes as high as 110°, and actually reaches a higher 
point after death. In a case observed by Wunderlich^ there was a mar- 
vellous elevation of this kind, and a very tardy fall after death. 

1 Archiv. der Heilkunde, Bd. ii., and v. (1861-63). Keported by Eadcliffe. 



372 



DISEASES OF THE SPINAL CORD. 



Date. 



24th July, 1861 

25th 

26th 



9 A. M. . 
6 P. M. . 
9.20 P. M 
9.35 P. M.. 
after death, 2^ 





« 


20^ 


(I 


(( 


35^ 


u 


« 


55^ 


<( 


u 


60^ 


<< 


ii 


70^ 


(( 


(( 


90^ 


ii 


(( 


100^ 


<( 


« 


6 hours 


a 


li 


9 '^ 


a 


u 


12 " 


« 


(i 


13^ " 



Pulse. 



96 

82 

96 

112 

180 



Temperature 
(Fahrenheit). 



102° 

102 

104.45 

103.55 

110.1 

112.55 

112.77 

113 

113.22 

113.55 

113.67 

113.55 

113.22 

113 

111.8 

106.25 

104 

102 

101 



Dr. Joseph Jones, of New Orleans, the author of one of the most able 
articles upon this subject that has ever appeared, has made numerous ex- 
aminations of the urine. He found that the quantity of urine excreted 
during the " active stages was greatly diminished from the normal stand- 
ard, and in the successful cases treated the amount increased with subsi- 
dence of the symptoms." He also found that the urea was increased 
during the active stages, and the uric acid was diminished. 

The diminution of the excretion of urine is by him supposed to be ac- 
counted for by the small quantity of fluids taken, and by the loss of liquid 
in profuse perspiration. 

The mind is perfectly clear throughout the disease, and the patient suf- 
fers great mental misery as he fully realizes his terrible condition ; and 
sleep is nearly always absent, this being one of the most distressing fea- 
tures of the disease. If this is obtained, even in brief snatches, the mus- 
cles are relaxed, and all spasms disappear for the time, but immediately 
reappear upon awaking. The probable cause of death is either the 
closure of the glottis, or exhaustion, which is an inevitable result of the 
violent muscular action. In new-born children the disease sometimes 
appears between the first and fifth days, the first symptoms noted being 
restlessness, trembling of the lower jaw, and desire for the breast, which 



TETANUS. 



373 



the child leaves almost immediately. At the end of twenty-four hours, 
or even earlier, the muscles of the jaw are felt to be contracted and rigid, 
and it cannot open its mouth ; there is a peculiarly aged expression upon 
its face, the skin of the forehead being wrinkled. The eyelids are closed, 
and the lips are compressed over the teeth. The head is drawn back, 
and general spasms of the muscles of the back follow. Periods of re- 
mission occur, and the patient is thrown into a paroxysm by the most 
trivial agencies. The skin is very red and dark, and after a series 
of paroxysms, which may continue for several days, death closes the 
scene. 

Causes. — Exposure to damp and cold are the only known exciting 
causes of the idiopathic variety ; and traumatisms of certain kinds, or 
accidents during parturition, precede the other form. A punctured 
wound, which may be received from a nail or splinter, is much more 
likely to give rise to tetanus than an incised wound; and injuries in 
which there is mangling or crushing of muscular tissue are frequently 
concerned in the production of the disease. Railroad injuries are therefore 
especially dangerous. Tetanus sometimes follows surgical operations, and it 
has been thought in these cases to depend upon partial section of some 
nerve-trunk. Dupuytren^ goes far enough to recommend re-amputation. 
It may be stated that in certain regions there are apparent endemic influ- 
ences at the time of such predisposition, when any surgical operation may 
have this termination. This local influence prevails in Cuba and other 
tropical countries, and in Long Island and in other parts of the American 
seaboard. 

Jones has collected the statistics of tetanus, and the following table 
shows its prevalence in hot climates : — 



Place. 


Period. 


Total deaths. 


Deaths from 
tetanus. 


Proportion. 


London 
Ireland 
New York 
Bombay 


1850-3-4 
1831-1851 
1819-1834 
1851-1853 


224,515 

1,187,374 

83,783 

42,651 


73 
238 
112 
912 


1 in 3075 
1 in 4987 
1 in 748 
1 in 46 



I am indebted to Dr. Charles Findlay, of Havana, Cuba, for the fol- 
lowing concise table, which shows the prevalence of the disease in that 
island : — 



^ Lefons Orales, tome ii. pp. 599-612. 



374 



DISEASES OF THE SPINAL COED. 





1872. 


1873. 


1874. 


1875. 


1876. 


Average. 






i 


'i 


-i 




s 


c 


S 


i 


^ 


w 

n 


i- 










G 


'5 
4 


C 
1— 1 

39 


3 

< 
3 


G 
1— 1 

~3i 


-5 
< 

4 


G 

G 
1— 1 

33 


"5 
6 


G 
1— 1 

17 


< 
4.2 






January, 


4 


47 


34.0 


Pop. of Havana, 




























250,000. 


February, 


^ 


29 


1 


30 


3 


18 


4 


30 


4 


30 


3.4 


27.4 


Births per annum, 
5000. 


March, 


6 


24 


3 


28 


4 


31 


5 


24 


4 


29 


4.4 


27.2 


Deaths by tetanus in 


April, 


6 


26 


5 


30 





24 


4 


18 


5 


26 


4.0 


24.8 


Adults=0.192 a year 
per 1000 inhabit'ts. 


May, 


3 


27 


1 


29 


3 


33 


5 


30 


3 


35 


30 


30.8 




June, 


2 


24 


3 


33 


2 


36 


5 


29 


5 


39 


3.4 


32.2 


Death of infantile 
tetanus. 


July, 


4 


2o 


5 


20 


4 


31 


3 


36 


3 


35 


3.8 


29.4 


7i per hun' red births 


August, 


3 


35 


5 


33 


5 


45 


5 


38 


2 


46 


4.0 


37.4 




September, 


3 


28 


1 


29 


3 


41 


3 


42 


6 


33 


3.2 


34.6 




October, 


1 


42 


6 


32 


3 


36 


1 


43 


4 


37 


3.0 


38.0 




November, 


6 


45 


4 


42 


4 


29 


3 


37 


6 


41 


4.6 


38.8 




December, 


2 


36 


4 


23 


4 


31 


5 


28 


7 


40 


4.3 


31.6 




12 months, 


45 


388 


42 


368 


38 


389 


47 


388 


55 


408 


48.4 
4.0 


382.2 
31.8 


Yearly average. 
Monthly average. 



Long Island, it seems, has gained an unenviable notoriety as a place 
where tetanus is exceedingly common ; but it will be seen that there is 
much exaggeration in the reports which, as a rule, come to us in the news- 
papers, and which are nearly always sensational. I have devoted some 
time to the investigation of the subject, and have written to several well 
known physicians of eastern Long Island, and have received two or 
three letters in reply. 

Dr. Stilwell, an old settler of Sag Harbor, whose opportunities for re- 
search have been quite extensive, writes as follows : '' About 20 years 
ago I came to this place to practice, and learning the fact of the preva- 
lence of tetanus, or its liability from certain accidents, I attempted an in- 
vestigation, but failed of any success or satisfaction. Several supposed 
cases having recovered naturally brought many cases under my observa- 
tion, but most of them died. Several did hot, and from my after-remarks 
here you will perceive the reason. I have never known the disease to 
exist as an epidemic, but it is apt at certain seasons of the year, to follow 
wounds. Hot and damp weather, with cool evenings, is its favorite sea- 
son." The Doctor has known but two instances of recovery from trauma- 
tic tetanus. 

When a patient has recovered from tetanus it has been by a very slow 
process, the period between the spasms lengthening until they finally dis- 
appeared. Under favorable circumstances this required several weeks. 
" I have known fatal cases of idiopathic tetanus in July and August 



TETANUS. 375 

caused by fatigue and overheating, and sitting down to cool off in the 
ocean breezes. Farmers have often informed me that the white frost on 
grass would give cattle lockjaw. I have known a horse driven to fatigue 
tuilied out to pasture in a cool night when white frost formed upon the 
grass, and die with tetanus. I have known horses, in the heat of summer 
driven seven miles to the seashore and there cooled off in the ocean 
breezes, die of the same disease. The multiplicity of cases occur in sum- 
mer and in the heated term with cool nights. A farmer bruised his 
thumb-nail and pulled turnips in a frosted field ; he died of tetanus." The 
other letters I have received are in substance very much like that of Dr. 
Stilwell, and none of them suggest that the disease is as frequent as it is 
generally supposed to be. Dr. Benjamin, of Riverhead, says : " I have 
practised thirty years in this village, have an average of about one case 
each year (others claim twice that number), and should think the other 
physicians in the Assembly District would average about the same ; if so, 
it would make nineteen cases each year with a population of 19,000. 
My opinion is that there has been no marked change in the past forty 
years as to its frequency or fatality. A very large proportion of our 
cases prove fatal in from one to three days. Of trismus nascentium I 
have had six cases during the past thirty years, all of which were fatal." 
The information that I have derived from popular sources is, however, 
somewhat contradictory. I learn that about Good Ground, which is 
nearly twenty miles west of Sag Harbor, there are times when traumatic 
tetanus is very common ; and it is not safe for any person who has re- 
ceived even the most trivial injury to remain in the neighborhood. 

Capt. Foster and Capt. Joseph Penny, of Ponquogue, which is upon 
the sea-coast, state that they have known of tetanus, which was very com- 
mon at certain seasons ; several of their friends have died, and others 
have moved temporarily from the place as soon as injured. It was not 
uncommon for women about to be confined to leave the locality ; and 
cases of trismus neonatorum were of quite frequent occurrence. One man 
whose foot had been crushed by a horse died in a few days. 

From Mr. Wells, of Quogue, I ascertained that the disease is confined 
almost entirely to the district extending from Moriches to East Hampton, 
and that at the extreme easterly end of the Island (Montauk Point) no case 
has been known to occur. So perfect is the immunity at this place, that 
colts are taken there to be castrated and not removed until the wound 
is healed. The disease is more common during the fall than at any other 
season. Mr. Wells has known of from twenty to twenty-five cases, mostly 
men and boys, in a district forty miles long, during the past five years. 
In this region castrated colts generally die soon after the operation. In 
one case, of which my informant knew, a man was shooting ducks in a 
battery ; his shot-gun accidentally went off, the charge removing about 
one-half of the great toe. The wound was not especially painful, but at 
the end of eight days convulsions began, and he died in thirty-six hours. 

Mr. White, of South Hampton, scratched his thumb with a briar in the 



376 



DISEASES OF THE SPINAL CORD 



field, and afterwards died. Mr. Hand, of Canoe Place, died after a slight 
injury to the ankle. Mr. Wells also told me that several cases followed 
wounds received in the field where a form of shell-fish known as the 
"horseshoe" (king-crab) is used for manure. By the fall these craw- 
fish have undergone advanced decomposition, and their long spines, which 
project in any direction, are very apt to wound the bare-footed field hand. 
These statements are entitled to some credence, for the doctor was very 
often not called in. At the eastern end of the island several cases of 
fatal tetanus within a very short time occurred in the practice of Dr. 
Trudeau, then of Little Neck. Along the Atlantic sea-board I am told 
that this disease is by no means uncommon, and that on the Southern 
sea-coast it is much more frequently met with than in higher latitudes 
In a very interesting communication from Dr. Findlay, of Havana, he 
mentions a case in which the application of a blister in a case of pleurisy 
was followed by fatal tetanus. The accompanying map will enable the 
reader to perceive the geographical distribution of endemic tetanus on 
Long Island, the dark spots showing the limit of the region, and the 
points where it prevails to the greatest extent. 

Fig. 58. 




Map of Suffolk County, Long Island^ — 1. Manor. 2. Riverhead. 3. Sag Harbor. 4. East 
Hampton. 5. South Hampton. 6. Ponquogue and Good Ground. 7. Quogue. 8. West Hampton 
9. East Moriches. 10. Centre Moriches. 11. Seatuck. 12. Greenport. 13. Montauk Point. 14. 
Bridge Hampton. Darkest spots indicate points of greatest prevalence. 

Cold climates have something to do with the production of tetanus, as 
we would infer from Dr Kane's statement that intense cold produced 
"an anomalous spasmodic afiection allied to tetanus," which afiected 
most of his party, destroyed two men, and killed all his dogs. Trismus 
neonatorum is supposed by VogeP to depend upon the formation of the 
cicatrix when the umbilical cord is roughly handled, and there is probably 
pressure of some nerve by the contraction of the cicatrix. 

1 Diseases of Children, p. 65. Translation by Eaphael, N. Y., 1870. 



TETANUS. 377 

Frost-bite may sometimes give rise to tetanus, and the following cases 
are examples of this kind : 

They occurred under the care of Dr. Bethune, of Toronto. The first 
was that of a farmer who was exposed to intense cold for about three 
hours while driving. His feet and fingers became severely frost-bitten 
without his becoming aware of the fact until he arrived home. On ad- 
mission to the Toronto General Hospital, four days later, the toes and 
the greater part of both feet were found in a condition of moist gangrene. 

The fingers and parts of both hands on the dorsal surface were black 
and dry. Four days after admission he was seized with tetanic symp- 
toms, which rapidly developed. Chloral hydrate in thirty-grain doses, 
with extract of Calabar bean in one-fourth-grain hypodermic doses, until 
five grains had been given, failed to combat the disease, and the patient 
died in thirty hours after the accession of the attack. 

The second case was that of a man who, having lain out in a barn all 
night, had both feet severely frost-bitten, subsequently becoming partially 
gangrenous. In this case trismus set in nine days after exposure, and 
soon developed into well-marked tetanus, to which the patient succumbed 
in about thirty hours.^ 

Morbid Anatomy and Pathology. — The older writers have 
written a great deal in regard to the morbid anatomy of tetanus ; but 
the collected facts throw no light upon the pathology, and are to a great 
degree valueless. 

Lockhart Clark ^ in 1865 found in six cases that there was degenera- 
tion of the gray substance of the cord. " The first case was reported at 
some length, and the lesion was found more or less from the origin of the 
second cervical nerves to the lumbar enlargement. At the second cervi- 
cal nerve, streaks and irregular areas of disintegration were observed in 
different parts of the gray substance, and particularly around the central 
canal, on the right side of which was a space of considerable size con- 
taining a finely granular fluid, with the debris of blood-vessels and nerves. 
The posterior and lateral white columns, especially along the edge of 
the various fissures which transmit blood-vessels, were damaged in a 
similar way, and in some sections the deeper portions of the posterior 
columns which rest upon the transverse commissure were softened to a con- 
siderable degree. This disintegration was still more marked in the cervical 
enlargement, chiefly behind and at the sides of the canal. The posterior 
commissure was wholly and the anterior partially destroyed by a fluid 
transparent and granular area. Throughout the cervical enlargement 
similar lesions were discovered, varying from a state of softening to one 
of complete solution, and diminishing at intervals or almost disappearing, 
to return shortly in the same form. At the upper part of the dorsal 
region the shape of the cord was much altered, and extensive lesions of 
the same kind were everywhere seen. In both lateral halves of the gray 



1 London Lancet, March, 1875. 

2 Med.-Chir. Trans., 1848 and 1865, and Med. Times and Gazette, 1865. 



378 DISEASES OF THE SPINAL COED. 

substance, the left lateral columns, the right antero-lateral column, the 
superficial portion of the anterior columns, and in the posterior columns 
similar appearances were found. Below this point there was less disease 
as far as the fourth dorsal vertebra. Here, in addition to the areas of dis- 
integration, large extravasations of blood were found along the whole 
lateral part of the gray substance on both sides of some sections, in one 
side only of others ; while the lumbar region manifested the same lesions 
as the cervical." 

Dr. James Tyson ^ has detailed two cases in which softening of the pos- 
terior columns occurred. In one of these there was extravasation of blood 
in the posterior columns, and to some extent from the vessels of the pia 
mater. The central gray commissure was destroyed. In the other case 
no extravasation was found in the posterior columns, but there was venous 
congestion of the dura mater. I was presented by Prof L. McLane Tif- 
fany, of Baltimore, with a piece of the cord of one of his patients who 
had died with tetanus following a severe burn- The pia mater was greatly 
thickened, and the small posterior arteries were enlarged. Throughout 
the section, which was viewed at first with a low power objective, I per- 
ceived a rather extensive increase of the neuroglia. The anterior nerve- 
roots appeared to be very well defined. Throughout the white and gray 
matter there was visible numerous round cells quite translucent and 
bright, which resembled somewhat colloid bodies. These were more 
plentiful in the posterior column. The vessels of the gray matter were 
all more or less enlarged, and some of them were surrounded by spaces 
which were considerably wider than the diameter of the vessel. The cells 
of the anterior cornua were quite disintegrated, and some had taken an 
oval form. Those that could be recognized were found to have broken 
processes, and many had granular contents. The nerve- trunks were un- 
aflfected. 

Arlong^ and Tripier, Erichsen, and Bouillaud found that the end of the 
nerve in the wound was diseased, and Lepelletier^ and Froriep* discovered 
in one case that the neurilemma of the nerves in the vicinity was the seat 
of inflammatory changes, which extended from the periphery to the cord. 
This latter appearance indicates an exceptional condition of affairs, and 
as for the nerve- change in the wound, it is not to be wondered at, for if 
there is any importance to be attached to the circumstance of the morbid 
appearance of an injured nerve, it is certainly inconsiderable when we 
consider how frequent must be such a pathological condition, and still 
there is not a proportionate amount of tetanus. 

Dr. R. W. Amidon,^ has lately published very full notes upon a case 
of tetanus, which throw some light upon the question of morbid anatomy, 
In this observation the disease followed an injury of the median nerve, 

^ The Practitioner, August, 1877. ^ Archives de Physiol., etc,. 1870. 

3 Eevue Medicale, iv., 1827. * Neue Notizen, 1837. 

* Some new points on the Path. Anatomy of Tetanus, Archives of Medicine, 
June, 1879. 



TETANUS. 379 

and the patient died five days afterwards. Microscopical examination 
revealed a variety of interesting meningeal, vascular and other lesions 
— those claiming our attention chiefly being the presence of vacuoles in 
the medulla and very decided changes in the region of the spinal acces- 
sory root-fibers especially, while the vagus, hypo-glossal and glosso- 
pharyngeal nerves were found to be the seat of vascular lesions. The 
symptoms pointing to implication of these nerves were quite pronounced. 

Our knowledge of the pathology of tetanus is based almost entirely 
upon the experiments of physiologists, and we are left somewhat in the 
dark as to 1 he questions : 1. Whether it is a central disease resulting 
from a morbid peripheral irritation which is reflected upon the cord. 
2. Whether it is a central disease per se, and the appearances noted after 
death are primary. 3. Whether the morbid changes are secondary to the 
symptoms, and due to mechanical causes. 

We have so far been taught how general spasm may be produced. 
MitchelP and Morehouse caused in animals very violent convulsions by 
injecting into the vertebral canal a half ounce of fluid, and very hot or 
very cold water seemed to aggravate the spasms. Cold applied to the 
spine, whether produced by the rhigoline spray or by ice, gave rise to 
the same phenomena. Cold to the medulla caused the animal to topple 
backward. 

Upon examination the vessels were found to be intensely congested. 
So far, we are furnished with the first link in our chain. Assuming that 
the spasmodic movements are due to a congestion of the cord, and con- 
ceding that pathological anatomy has furnished us in nearly every instance 
with evidence of congestion of the gray matter, we are to discover what 
is the factor of such congestion. It may depend upon a reflected impres- 
sion transmitted to the vaso-dilators, or it may depend upon local irrita- 
tion by impure blood which produces secondary hypersemia. In strych- 
nine poisoning, the symptoms of which resemble those of tetanus very 
closely, the spasmodic phenomena are undoubtedly due to the imperfect 
oxygenation of the blood ; consequently the cord is supplied with blood 
loaded with carbonic oxide. It seems to me very possible that the 
same condition of aflTairs exists in tetanus ; that there may be direct irri- 
tation of the nervous matter of the cord dependent upon some primary 
blood condition. 

Fox^ very clearly expresses himself as follows : " The abnormal blood 
imperfectly nourished the cord. An imperfectly nourished cord is ipso 
facto an excitable, an impressible cord ; this impressibility renders arte- 
rial spasms abnormally facile, whether the exciting cause is the circula- 
tion in the cord of more of the morbid blood, or reflected irritation from 
a diseased nerve at the periphery, or reflex irritation from any other 
cause and from any other point in the body, and if this arterial contrac- 
tion goes on for any protracted period, or is frequently repeated, we may 



1 Am. Journ. Med. Sciences, 1866. ^ Op_ ^i'., p. 362. 



380 DISEASES OF THE SPINAL CORD. 

find various lesions due to imperfect blood-supply in addition to those due 
to diminished nutrition from the original nature of the blood, while, as a 
sequence of the spasmodic arterial contractions, we get hypersemia, and 
perhaps exudation, and lastly the pressure of the exudation or some 
peculiarity in its nature may lead to some disintegration of the nervous 
centres." 

This theory seems to me to be tenable for several reasons : 1, Inju- 
ries of peripheral nerves are common, and the cases of resulting tetanus 
are out of all proportion to those presenting no subsequent nervous symp- 
toms. 2. Its endemic nature, its prevalence in certain districts, and its 
not uncommon idiopathic origin when there is no ascertained eccentric 
cause. 3. The appearances of the cord are of a destructive character, 
and it is a matter of doubt whether they are not more a result than a 
cause. 

Considerable discussion has taken place in regard to the cause of the 
high elevation of temperature. Verneuil does not consider it due either to 
myelitis of the superior part of the cord, or to asphyxia or muscular con- 
tractions ; but Mason is decidedly of the opinion that such increase in 
temperature is alone the result of muscular action. The experiment of 
Mason has shown that the temperature of a tetanized muscle is often 
increased from one to two degrees. 

The medulla has been found to be the seat of grave lesions, such 
as in Amidon's case for example, and it is probable that the trismus 
and other evidences of an excited state of cranial nerve innervation, 
which occur in the beginning, are indications of primary disturbances 
in the bulb. 

Diagnosis. — The diseases and conditions with which tetanus may be 
confounded are hydrophobia, strychnine poisoning, hysteria, and acute spinal 
meningitis. In the first there is no risus sardonicus ; the convulsions are 
clonic ; there is the noisy hawking and effort to spit ; the dread of water, 
the delirium, and finally the history of a bite by a rabid animal, which, 
however, is not always ascertained. Strychnine poisoning is very easily 
mistaken for tetanus. In poisoning by a large dose of the alkaloid the 
symptoms appear rapidly, and death takes place in a short time. The hands 
are clenched and rigid, but the jaw can be opened, which is not possible in 
tetanus This resemblance between the two conditions has been made 
use of in more than one poisoning case as a ground of defence, and in 
that of Cooke, who was poisoned by Palmer, the question was narrowed 
down to the appearance of the cord. Cases of hysteria sometimes present 
symptoms which not rarely counterfeit those of tetanus. The jaw may 
be locked, but there will be few of the other features. Hysterical pa- 
tients are nearly always seemingly unconscious, and there are no evi- 
dences of suffering whatever. In spinal meningitis the muscular rigidity 
seems to be dependent, in a great measure, upon the patient's efforts to 
relieve the pain which is produced by an uncomfortable position. The 
locked jaw, which is an early symptom of tetanus, is absent in acute spi- 
nal meningitis. 



TETANUS. 381 

Prognosis. — Dr. Jones ^ has collected 480 cases of tetanus, 213 of 
which recovered under treatment, the mortality being 49.2 per cent., or 
one death in 2.02. These were all cases of traumatic tetanus. The per- 
centage of death in the British army during the Crimean War was 91 per 
cent- ; and Baron Larrey's estimate of mortality of the French army under 
Napoleon was at about the same rate. 

In regard to the time of death Dr. Jones found that of 50 cases, in 
which the disease followed slight injury of the extremities, 43 proved 
fatal in a short time, and of the whole number of deaths reported 24.14 
per cent, ran a rapid course after slight injuries, and terminated in death 
in a few days. One case died on the second day. Cases are reported 
which have terminated fatally in twenty-four hours after the appearance 
of symptoms. In one case, mentioned by Dazelle, they appeared on the 
third day, and the patient died the same night. One author lays stress 
upon the statement that the prognosis is governed by the interval that 
elapses between the receipt of the wound and the appearance of the 
symptoms, and that the longer this interval is the more favorable are the 
patient's chances. Many writers agree that elevated temperature plays 
an important part in the prognosis, and that any increase is to be looked 
upon with alarm. The duration of the attack is to be taken into account, 
and every day bridged over by the patient after the fourth or fifth in- 
creases his chances of recovery. Of course the gravity of the affection 
depends much upon the violence of the paroxysms. 

Treatment. — It would be useless to discuss the merits of the many 
drugs that have been brought forward from time to time. Our most effi- 
cacious remedial agents are the depresso-motors, and among these may be 
mentioned chloroform, chloral hydrate, Indian hemp, Calabar bean, and 
conium. 

Calabar bean, which has enjoyed a deserved popularity, has been made 
use of wdth great success by Eilert, Holhouse, Wood, Watson, and a host 
of others. Holhouse in 1864 reported two cases, one of which was cured 
after having taken 3-4J grains of the extract every two hours. Ashdown 
was not so successful, and Spencer and Dickenson had the same discourag- 
ing experience. Even Watson was one of the first to use the remedy, 
and three out of his four cases of tetanus were cured by the administra- 
tion of ten drops of the tincture every hour, and by a subsequent increase 
in the dose. The drug may be given in full doses, say from one-quarter 
to one-third of a grain of the extract every two hours. 

The chloral treatment has certainly been more efficacious. Surgeon- 
Major Hunter^ reported two cases : one a boy, and the other a man of 40. 
In the first case chloral was combined with cannabis indica. B. Tr. can- 
nabis ind. HXx ; potass, bromid. gr. v, every third morning ; and chloral 
hydrat. gr. xij, three times a day, together with inhalations of chloroform 



^Medical and Surgical Memoirs, vol. i., New Orleans, 1876. 
2 Indian Med. Gaz., Feb. 1, 1875. 



382 DISEASES OF THE SPIl^AL CORD. 

as required. The other patient took 20 grains of the chloral thrice 
daily. Opium and chloral in combination have perhaps been more ef- 
fective than the chloral alone, and DelsaP saved three cases out of four 
by this treatment. H. C. Wood reports 9 cures by chloral out of 18 
cases. 

Chloroform has not proved to be the valuable remedy that many have 
supposed it to be, and it has only the power to " crowd down the bad 
symptoms which burst forth usually with additional fury when the narcosis 
subsides." 

Aconite has been of service upon many occasions. It was tirst used by 
Page^ in a case of traumatic tetanus. The toxic effects of the drug were 
produced, and during their continuance there was a remission of symptoms. 
The patient was first reduced to a condition bordering on syncope, and af- 
terwards stimulated. De Morgan and others cured tetanus with this reme- 
dy, and its place in the therapeutics of the affection is by no means an in- 
ferior one. The pulse is markedly lowered, the muscular rigidity relaxed 
and a condition cf akinesis and prostration takes the place of the irritable 
nervous state. Curare, nitrite of amy 1. and belladonna, as well as a host 
of remedies of the same character, have been praised from time to time ; 
but most of them are useless. Chloral hydrate, either in combination 
with aconite, or chloroform, and cold to the spine, which may be applied 
by the ether spray as recommended by Carpenter, I think is the best 
form of treatment, and should be resorted to as early as possible. If 
these remedies fail. Calabar bean, hyoscyamin, curare, or nitrite of amyl 
may be tried, and conium, which is a powerful depressor of spinal exci- 
tability, may be given a trial. Warm baths have been recommended. 

"Dr. F. Franzolini^ relates a case of tetanus arising from exposure by 
sleeping on the damp ground after great fatigue, successfully treated by 
prolonged warm baths and the continual use of chloral and morphia. 
The chloral was given frequently by the stomach, and the morphia by 
subcutaneous injection. The first bath was for six hours, at a tempera- 
ture of 40° C. (104° F.), and subsequent ones lasted five, four, three, or 
two hours. This treatment was carried out from the 18th to the 30th of 
the month ; but the daily use of chloral and morphia was continued some 
time longer. Of the first ninety hours of his disease, the patient passed 
forty-eight in the bath at 40° C. In twenty-nine days he consumed nearly 
four ounces of chloral hydrate, and about twenty-two grains of hydro- 
chlorate of morphia were injected. Although kept so long in a state of 
almost constant narcotism, the mental powers of the patient were in no 
way affected." 

H. de Renzi,* of Genoa, has spoken highly of the dark-room treatment. 
His patient was kept absolutely quiet. He ascribes the success to the 

^ Quoted in Practitioner, August, 1877. 

2 Lancet, April 4, 1846. 

3 The Doctor, Oct. 1, 1875. Aba. in Phila. Med. Times, Oct, 30, 1875. 
* Gaz. Med. de Paris. No. 32, 1877. 



TETANUS. 383 

belief that the absorption of oxygen and elimination of carbonic oxide 
are impeded by darkness. 

The other indications seemed to be perfect quiet, and during and after 
tlie attack ample nourishment. Niemeyer^ believes in clysters containing 
twenty or thirty drops of laudanum. He also recommends chamomile 
baths in the infantile variety. 

^ Text-Book of Tract. Med., vol. ii. p. 352. 



384 BULBAR DISEASES. 



CHAPTER XIII. 

BULBAR DISEASES. 
EPILEPSY. 

Synonyms. — L'Epilepsie (Fr.) ; Fallsucht (Ger.) ; Mai caduco 
(Ital.). 

Definition. — This most familiar of all nervous diseases is character- 
ized by loss of coDsciousness of variable duration, attended or unattended 
by either slight muscular spasms or general convulsions. 

The relation of these two elements, the psychical and physical, is not 
always the same, as in some forms of the disease there is a momentary 
loss of consciousness and perhaps no appreciable spasm, or the two may 
co-exist, there being protracted loss of consciousness and violent convul- 
sions. There are sometimes very peculiar combinations of symptvoms 
■which will receive mention hereafter. 

The modern investigation of epilepsy by Hughlings Jackson has mate- 
rially modified our views of the disease. His consideration of the patho- 
logy of the disease is exceedingly complex, and he is inclined to, treat 
the subject with greater breadth, and give it greater importance than it 
ever has received. A disruption of the most transient description of 
the harmonious relation of the psychical centres gives rise to a genuine 
paroxysm or discharge, so that many temporary bizarre actions which 
most of us indulge in even in comparative health, become invested with a 
new significance. Certain phases of what we indefinitely call " absent- 
mindedness," leading us to commit absurd acts which we laugh at after 
they are performed, may be in reality genuine epilepsies, and in others 
may attain the importance of disease symptoms. 

The scope of this work does not permit me to consider the history of 
the disease ; suffice it to say, that its antiquity dates back to the days of 
Hippocrates and Aretseus, and biblical references to its existence are 
common. 

Cook ^ thus speaks of the early writings : " Epilepsy has been distin- 
guished by a great variety of names such as morbus sacer, comitialis her- 
culeus, caducus, etc. Aretseus says, it may have been called sacred on 
account of the magnitude of the evil, it being customary to call what is 
great by that name ; or because it is to be cured rather by the Divine 
than by human power, or because persons laboring under it have been 
thought possessed by" demons.^ . . . Some of the ancients were of 

1 Treatise on Nervous Diseases, Am. ed., 1824, p. 326. 

2 Aret. de Caus. et Sign, Morb,, lib. i. c. 4. 



EPILEPSY. 385 

opinion that epilepsy was denominated the Herculean disease because 
Hercules was subject to it; but Galen says, it was so called on account 
of its form or magnitude." 

"Epilepsy was denominated morbus comitialis, either because it fre- 
quently occurred in the crowded assemblies of the Romans called comltia, 
in which the passions of the people were often much excited, by which it 
might be occasioned, or because it was customary to dissolve the comltia 
if during the sitting any person should be aifected by it. 

" The application of the term caducus, a falling sickness, is too evident 
to need illustration." 

In our description of the aifection it is impossible to make any well- 
defined division ; suffice it to say, that all writers recognize forms known 
as ffaut mal or Epilepsia gravior, and Petit mal or Epilepsia mitior. 
Eeynolds divides the latter into two varieties, viz.: 1st. A form with evi- 
dent spasms, and another ivithout evident spasms. Besides these, various 
irregular forms have been included, such as masked epilepsy and hystero- 
epilepsy. 

THE GRAVE ATTACK. 

Symptoms. — The most familiar variety is known as Epilepsia gra- 
vior, and it may be described as an attack expressed in four stages : 1st. 
A premonitory stage ; 2d. Stage of convulsion ; 3d. Stage of subsidence ; 
and 4th. A stage of stupor, or " after -stage " (Reynolds). The first stage 
may often be absent, for in many cases there is Si sudden debut ; but if 
such be not the case, the patient may have -well recognized warnings which 
may be either psychical (mental or emotional), motorial, sensorial, or 
vascular, these latter being objective indications. Though these warn- 
ings are spoken of by many patients, it is almost impossible to rely upon 
their testimony, as the demoralization dependent upon the anticipation 
of the attack, or the short duration of such premonitory symptoms, is 
sufficient to prevent them from analyzing their feelings. It is, however, 
possible in many instances to collect information from a number of cases 
which shall be a basis for the general classification of premonitory 
symptoms. 

Very often the attack will be immediately preceded by a vague dread, 
or an undefined fear of some impending trouble. 

In one of my cases — a remarkably clever and intelligent young hdy — 
there is a condition of exhilaration of spirit, and a mental activity which 
lasts for some hours. Although deeply under the iafluence of the bro- 
mide, she will come out of her apathetic state and chat with her friends 
upon all subjects in the most entertaining manner. Twitching of the 
eyelids or of the lower extremies, vertigo with rotatory movement, and 
tremor are examples of the disorders of the motility which occasionally 
precede the attack. Sometimes there is an elevated" sensitiveness of the 
organs of special sense. 

Hallucinations of hearing and visual hallucinations are not uncommon. 
One of my patients has often seen a fiery cross; and another refers to a 
25 



386 BULBAE DISEASES. 

locomotive with a glaring headlight, which rushes upon him , while a 
third hears voices ; and in two cases the patients say that they " smell 
smoke." Morbid sensations, which cannot be defined, are spoken of oc- 
casionally, and a vague sense of weight in the epigastrium, head, or some 
other part of the body is a frequent precursor of the attack. Occasionally 
the peculiar sensations begin at some remote part of the body, and seem 
to move rapidly towards the head ; such phenomena are known as aurcB. 
These auroe have been compared to the blowing of wind over the surface, 
the creeping of insects upon the skin, or the pricking of needles. They 
last but a few seconds, and are sometimes perceived, but not always. 
In the wards under my charge at the Epileptic Hospital, the patients 
sometimes have perceived the auroe in time to seek the nurse or attract 
the notice of the other patients. Careful investigation of twenty-nine 
cases resulted in the discovery that eighteen of them had a warniog of 
some kind, four had none, and the rest gave us unsatisfactory answers. 
After a long process of condensation of statements, I find that seven had 
an aura starting from the epigastric region, two conjplained of constric- 
tion of the chest, seven had slight vertigo, and one had an aura starting 
from the extremities, and in one there was trembling of the right hand. 
Headache preceded the attack in four, and the " indescribable feeling " of 
the coming fit was alluded to by a number. In one remarkable case the 
first intimation of the attack was the violent jerking of the head to one 
side, and a species of vertigo. In another case the patient muttered in- 
coherently for a full minute before the actual attack. A third case was 
equall}^ curious. The patient, whose mental condition was good, would, 
without any apparent reason, attract the attention of persons about him 
by the repetition of the sylables " be-lub-be-lub, be-lub, lub, lub-a-lub, 
a-lub," pitching his voice in a high key, and gradually lowering the tone 
until the last part of his utterance was hushed and low, and then, after 
giving vent to a species of groan, he would become convulsed. Trous- 
seau^ calls attention to the "vascular prodromata." A local determina- 
tion of blood may occur in the finger, for instance, causing it to swell, 
reddening the skin, and rendering it successively, within a very short 
time, red, and of a more or less deep violet color ; or, again, the skin 
may become excessively pale after having been injected for some time. 
The swelling is real, not apparent ; for rings previously easy suddenly 
become too tight for the finger. The only premonitory symptom may some- 
times be an involuntary discharge of urine. It is difficult to distinguish 
this accident, however, and it is very liable to be considered a part of the 
attack, which it may be in reality. ^Dr. Hughlings Jackson has made 
a contribution of the study of aur^e with reference to localization. When 
the epileptic paroxysm is preceded by vertigo with apparent rotation 
of objects, the attack begins on the right side and indicates a cortical 
lesion of the opposite side. When the aurse consist in perception of odors. 



1 Clinical Medicine, Am. ed., vol. i. p. 75. ' " Brain," Julv, 18S0. 



EPILEPSY. 387 

or epigastric sensation, or when masticatory movements of the jaw occur, 
the convulsions begin on the left side. 

2d Stage {Stage of Convulsion). — In many cases the first indication of 
the attack is a wild cry, which startles those about the patient. I have 
seen a soldier marching in procession throw up his gun and shriek so loud 
as to be heard half a block away, and fall to the pavement in a convul- 
sion. This shriek is a psychical manifestation, and different from another 
form of cry which the patient may utter. This second variety is less 
noisy, and is produced by the forcible expulsion of air through the vocal 
cords which follows spasm of the thoracic muscles. It is more a species 
of groan. Simultaneously there is loss of consciousness, and the patient 
falls to the ground, and is agitated by tonic contraction of all the muscles 
of the body, but usually those of one side more than the other ; so that his 
body is twisted and bent. The muscles of the neck are strongly contrac- 
ted, while the face is generally distorted. The stronger contraction of 
some muscles than others draws the weaker side so that movements are 
produced which are not the result of clonic contraction, but rather an evi- 
dence of unequally expended forces/ Respiration stops, or there may be 
a long expiration, and then stoppage altogether for a few seconds. The 
pulse is now rapid and very small, a result, probably, of compression of 
the arteries by muscular masses, and the heart-beats are strong. At the 
end of a few seconds, and rarely after a minute, the convulsions become 
clonic, the patient throwing his arms about violently, or bumping the back 
of his head upon the floor. He is still unconscious, and may have evacua- 
tions from his bowels and bladder, or, as in some of the cases that I have 
seen, there may be an emission of semen. Reynolds calls attention to 
vomiting, a symptom which I have several times witnessed. The respira- 
tion now becomes labored and rapid, and there may be snoring. Froth 
collects about the mouth, which may be tinged with blood, as the patient 
sometimes bites his tongue or lips. The surface, which was in the first 
stage quite pale and cool, now becomes dusky, and of a dark livid color. 
The pupils may remain dilated as they were at the onset of the attack, or 
may be unequal. From my note-book I find that the following points 
were observed in the twenty-nine cases previously alluded to. In twenty- 
six the convulsions were quite general. In three the legs were more con- 
vulsed than any other part. In three the arms were especially agitated. 
In one patient the movements were confined to the left side. The cry was 
very piercing in five instances. In three there was only a moan or gurg- 
ling expiratory sound. Twenty -four of these patients bit their tongues. 
In twenty-three the pupils were wildly dilated. In two the dilation was 
not so marked. In four no appreciable difference was noticed. After the 
stage of tonic convulsion, which lasts a few minutes, the third stage is 
reached. In the large number of cases the attack may begin by local 
convulsive movements in the hand or in some of the muscles of the face. 
The thumb may be sharply turned in and the fist clenched — the convul- 
sion then becomes general. 

^Eeynolds. 



388 BULBAR DISEASES. 

Sd Stage (Stage of Subsidence). — This is marked by a gradual return 
of consciousness. The patient may stupidly turn his head or look up- 
wards, the eyes having a meaningless expression, and the balls oscillating 
slightly. He may strive to express himself, but only gives utterance to 
a series of unintelligible sounds. He may make some effort to rise, 
but finds it impossible to do so. His pulse is small and thready, or 
sometimes full and bounding, especially when the first two stages have 
been short. His eyes are injected, and his pupils either normal or con- 
tracted. 

Ath Stage (Stage of Stupor). — Exhausted by his attack, he falls into a 
sound sleep, which is so profound that he lies where he has fallen, and re- 
sents any attempt to remove him. The stupor may be so deep, however, 
as to make him unmindful of what is going on about him. His sleep 
lasts for several hours, and is characterized by snoring. If the patient 
recovers without the stupor, he is very irritable and cross. He complains 
of headache, or perhaps nausea, and vomits ; and his pulse is irritable and 
irregular. Thompson^ calls attention to the tracings obtained in epilepsy 
when the heart is healthy, and it is possible to obtain good results. He 
as well as Lorain found that the sphygmograph tracing exhibited a distinct 
dicrotic notch. 

In regard to the time of attack, two divisions have been made — noc- 
turnal and diurnal. I have thought it best to make another, viz. : ma- 
tutinal. 

Perhaps nocturnal epilepsy is much more common than the other forms, 
for a great many patients never have attacks at any other time, while 
some may have them at all times, and a few only during the day. A 
large number are attacked just as they awaken ; and I have met this 
form so frequently that I prefer to use the term matutinal for the attacks 
occurring between five and nine in the morning. The only sign of a noc- 
turnal attack may be the evidence of involuntary passages of urine* and 
feces, and sometimes both. Blood upon the bed linen as a consequence of 
tongue-biting h another indication, and the trouble which is required to 
rouse the patient is a third. Of forty-eight patients, fourteen had their 
attacks at irregular hours, seventeen had them at night only, five in the 
day, and twelve in the morning. 

The patient may sometimes do himself bodily harm during the convul- 
sion and Dr. Maury, of Memphis, has communicated to me the following 
two cases of dislocation of the bones during an epileptic paroxysm. This 
is a rare accident in epilepsy, although it is not uncommon in tetanus. 

Case I. A man from Holly Springs, Miss., was sent to Dr. M. in Dec. 
1876. The patient was sixty years of age, a planter, and of good habits. 
About one year before, after eating his supper, he became ill and had 
convulsions. In the night he had fresh convulsions, and suffered con- 
siderably from pain in the right shoulder The convulsions recurred 
at intervals of ten days. When he was brought to Dr. M. the 

1 West Eiding Eeports, vo]. ii. p. 303. 



EPILEPSY. 389 

shoulder was found to be shrunken, and the humerus dislocated and im- 
movable. 

Case II. A lady from Alabama, during the menopause, was affected 
with epilepsy about two years and a half before the Doctor saw her. She 
was attacked at night with convulsions and pain in left hip. These at- 
tacks occurred at intervals of from two to four weeks before she was seen 
by a physician. Left lower extremity found to be shortened about two 
inches, femur evidently dislocated. Muscular contraction on outside of 
leg ; toes everted, and thigh turned inwards In this case no attempt was 
made to reduce the dislocation. Whenever she had convulsions there was 
pain in region of liver. 

THE LIGHT ATTACK. 

Symptoms. — The lighter forms of epilepsy are included under the 
head of Epilepsia mitior, and are attended by a very transitory loss of 
consciousness. There may be little or absolutely no spasm, and the attack 
may be so unpronounced as to escape the notice of those persons who may 
happen to be present. The patient may be eating at the time, and sud- 
denly drop his knife and fork ; or he may be engaged in some occupa- 
tion, and suspend operations for a second. In one of my patients the 
only indication of the attack was the rolling upwards of the eyes. 
Another, a gentleman, when writing would stop for a moment and go 
on with his work entirely unconscious of any interruption. If walk- 
ing, there may be a sudden loss of equilibrium, but he rarely falls. The 
face may be blanched or flushed momentarily, and the patient may 
suffer no bodily discomfort, but is sometimes restless, depressed, or low- 
spirited. 

An aggravated state may exist, in which the muscular spasms are more 
marked. 

The attacks, which have been described as " weak spells," or " fainting 
fits," by uninformed people, consist in more protracted loss of conscious- 
ness, accompanied perhaps by strong muscular contractions of the muscles 
of the face or arms, pallor, and dilatation of the pupils. I have a patient 
under observation who has a distinct epigastric aura; she then becomes 
rigid, holds her breath, grasps the arms of her chair ; her head is drawn 
forwards, and so she remains for a minute or two. 

The foregoing forms may coexist, there being distinct attacks of grand 
mal, with repeated petit mal seizures, which seem to have no special rela- 
tion to the more serious convulsions. Twelve of the twenty-nine cases 
suffered from grand mal alone, and seventeen had both forms, and in these 
cases the petit mal predominated. 

As to periodicity and frequency of the attacks there is much to be said. 
There is a peculiarity in the regularity of the seizures which is to be 
observed in very many cases. A tendency to weekly, semi-monthly, or 
monthly recurrence is noticed. 

When the fits take place there may be only one at a time, or there may 



390 BULBAR DISEASES. 

be a number witbin twenty-four hours, or two or three days, and then an 
interval of the duration I have just described elapses before a fresh attack 
or series of attacks takes place. 

In Reynolds's experience there are four times as many epileptics who 
have their attacks more frequently than once a month as there are who 
have them at long intervals ; but I am disinclined to agree with him 
" that males are more subject to monthly attacks than females, and that 
attacks in the latter are not as a rule monthly seizures." 

I discover every day numerous verifications of the menstrual influence. 
In forty patients I find that eighteen occur during or just after the days 
the woman has her catamenia ; and in more thaa one case much interest 
arises from the fact that there was dysmenorrhcea, and that when this 
was relieved the attacks disappeared. 

In many chronic cases, especially when there are complications, there 
is rarely any regularity in the appearance of the attacks. In the Epi- 
leptic Hospital, on Blackwell's Island, I find extreme variation in their 
number ; and there are patients under treatment who have had but three 
or four attacks in one year, while there are others who generally have 
from five to thirty each week; but this great frequency is exceptional. 
The attacks of petit mal are much more numerous, but from their very 
transitory character it is difficult to make any estimate which is at all 
useful. The irregular forms of the disease are of greater interest as curi- 
osities than anything else, but derive some importance from their medico- 
legal bearing. 

IRREGULAR ATTACKS. 

There may be a form known as aborted epilepsy, which consists in the 
expression of all the features of ordinary haut mal, without complete loss 
cf consciousness. The attacks may occur in the course of ordinary epi- 
lepsy. 

The most peculiar examples of irregular seizures are described by Fal- 
ret, Hughliugs Jackson, and others. While in certain states the patient 
will do the most eccentric things imaginable, the mind being apparently 
in a condition of vacuity, and the individual becomes more an automaton 
thp.n a human being. 

^Mesnet; of the St. Antoine Hospital, came across a very interesting 
case. The patient has been known as the " Automatic Man," and his 
hiotory is as follows : — 

" A young man during the late war had a portion of the left parietal 
bone, about eight centimetres in extent, carried away by a ball. Hemi- 
plegia of the right side was the consequence, but this gradually disap- 
peared. For some time past he has been the subject of attacks, lasting 
from twenty-four to forty-eight hours, attended by very extraordinary 
phenomena. During these he seems to act exactly like an automaton, 
walking continuously, incessantly moving his jaw, knitting his brow, and 

1 Gazette Hehdomadaire, JuJy 17, 1874. 



EPILEPSY. 391 

appearing absolutely insensible to all that surrounds him. ISTot uttering 
a word, he walks straight forward, and when he meets with an obstacle, 
stops short, explores it with his hand, and tries to pass on one side of it. 
Surrounded by a circle of persons, he stops at each, and endeavors to pass 
by the intervals formed by their joined hands, then turns back, comes in 
contact with the next person, and resumes his round. All this time he 
never manifests the slightest consciousness, just as if he were in a state of 
somnambulism. He is absolutely insensible to pain, so that pins may be 
thrust through the cheek or into the fingers, or very powerful electric 
shocks may be administered without the slightest sensibility being mani- 
fested. What, however, is very remarkable, is that by bringing him in 
relation with certain objects we are enabled to determine in him the entire 
series of acts which are correlative wifh the sensation thus aroused. Thus, 
if a pen be placed in his hand, he seeks for ink and paper, and writes a 
letter in a very good hand, in which he speaks very sensibly about differ- 
ent matters which concern him. If a leaf of cigarette paper is placed in 
his hand, he feels in his pocket for the tobacco, rolls up the cigarette very 
adroitly, ard, having found his match-box, lights it. If the match beex- 
tinguisiied just as it reaches the cigarette, he finds another, and that 
several times, until he is allowed to light his cigarette. If at the moment 
when the match is extinguished, another already lighted is presented to 
him in its place, it is impossible to induce him to light the cigarette by 
means of the substituted match. He allows his moustaches to become 
burned without ofiering any resistance, but he will not employ the light 
thus presented to him. If chopped charpie be placed in his pocket in- 
stead of his tobacco, he makes the cigarette with this, and lights and 
smokes it without seeming to pay any attention to what he is smoking. 

Among the various experiments devised by Dr. Mesnet, there is one 
which is particularly curious. The young man is a singer at concerts by 
profession, and if gloves be placed in his hands he immediately puts them 
on, and searches for paper. When a roll of this, resembling music in form, 
is given to him, he places himself in the proper position and begins to sing. 
It would seem, in fact, that tactile sensation induced in him becomes the 
point of departure, and as if of escape, of a series of acts correlative to this 
initial sensation — acts which he accomplishes automatically, without 
letting them deviate from their habitual and regular succession. Lastly, 
it is to be noted that, while in this singular condition, the patient steals all 
that comes within his grasp. If he touches any person, he feels for his 
watch-pocket, and invariably detaches the watch and puts it in his own 
pocket, whence it may be immediately removed without his making the 
slightest opposition. The crisis once over, he has no recollection what- 
ever of what he has been doing, and becomes again perfectly reason- 
able." ^ 

Equally curious cases are reported by Jackson of individuals who 
do purposeless things knowing nothing about them afterward. A pa- 
tient of my own upon several occasions in a condition akin to " brown 
study," walked from the ferry-boat into the wrong car and rode some 
miles before he discovered his mistake. Many of the curious cases of 
absent-mindedness reported by various authors were undoubtedly irregu- 
lar forms of epilepsy. 

1 Med. Times and Gazette, July 25, 1S74. 



392 BULBAR DISEASES. 

An irregular form of the disease is known as " masked epilepsy." The 
patient in this state may not fall to the ground, but while in a state of 
unconsciousness will evince a great deal of muscular activity. An 
epileptic in my ward is in the habit of tearing through the hall, col- 
liding with such patients as may happen to be in her way, and finally 
recovering consciousness, when she has no recollection of her attack. I 
have noticed the same phenomena in other cases. 

Another form is connected with the commission of purposeless acts such 
as I have cited. Cases of persons who have disappeared and travelled about 
the country for some days, and when found could not give the slightest 
history of their whereabouts are reported by various authorities. Snch 
individuals in reality, lead a double life, and while the automatic state pre- 
vails they may commit deeds of violence which may subsequently cause 
a great deal of trouble ; and in such cases only, the history of undoubted 
epilepsy should alone be sufficient to exonerate them. I believe it is 
strongly improbable that there is ever an attack of masked or aborted 
epilepsy without expression of some of the evidences of the true par- 
oxysm. 

The sequences of epilepsy are various, but it does not necessarily follow 
that any mental impairment should result. It is true that in some cases 
such a termination is possible. Idiocy and epilepsy sometimes go together, 
but it must be remembered that the former is a congenital state. Ex- 
amples of general mental failure are by no means rare, and in some cases 
the disease slowly undermines the patient's intellectual condition. An 
apathetic ^tate is the primary result. Any one who has seen one of these 
old cases (especially if the patient be the victim of petit mat), with dull 
fishy expression of eyes, dilatation of pupils, a leaden, sallow counte- 
nance, a full lip with imperfectly defined vermillion border, sluggish cu- 
taneous circulation, loss of memory, and dulness of wits, will recognize 
the condition I have endeavored to describe. Dr. Gray,^ of Brooklyn, 
has directed attention to what he believes to be a certain test of the epi- 
leptic state. He finds that the pupils of epileptics respond much more 
actively to the stimulus of light than in the normal individual. I cannot 
say that I have been struck with this condition Dr. Gill, the Resident 
Physician of the Hospital for Epileptics or Paralytics, made an examina- 
tion of the eyes of twenty-seven epileptics. Of this number, there was 
ready response in eighteen cases ; of the remainder, seven responded 
slowly. In one other case the pupils were dilated, and responded only 
when a bright light was brought directly upon pupil. In the remaining 
case the pupils were contracted, and responded with great difficulty. 
Of fifteen cases, most of which were of recent date, the pupillary response 
was not remarkably rapid- The first eighteen cases were of long stand- 
ing. In nearly all of these cases there was dilatation to a great extent 
under ordinary circumstances, and I attach much more importance to this 
appearance. When it is borne in mind that at best epilepsy is often a 

Am. Jour, of Med. Science, 1880. 



EPILEPSY. 



3^3 



symptomatic condition of various organic troubles which may affect the 
eyes in different ways it is difficult to attach pathognomonic importance 
to ocular tests. 

An epileptic convulsion in infancy may give rise to cerebral hemor- 
rhage from a vessel ruptured during the paroxysm, but the accident is al- 
most unheard of in adult life. 

Epileptic mania, which Reynolds considers to occur in about one-tenth 
of all the cases, is not confined to any particular time. It may occur be- 
fore the attacks, or, as is more often the case, succeed them. In this con- 
dition epileptics may be occasionally very dangerous, and give way to 
outbursts of violence, for which, of course, they are entirely irresponsible. 

A man who was a patient in the out-door department of the N. Y. State 
Hospital for Diseases of the Nervous System, and who had been 
treated by Dr. J. J. Mason, for epilepsy for a long time, was subse- 
quently discharged, as it was supposed, cured. A month or two after- 
wards, having an attack which was undoubtedly epileptic mania, he pur- 
sued his wife through the streets, and, drawing a pistol, shot her through 
the heart. After the deed he expressed great remorse, and gave himself 
up to the authorities, but, notwithstanding the medical testimony, was 
sentenced to the State's prison for life. 

Causes. — Of one hundred and eighty-three cases of epilepsy I have 
seen at various times, the ages at which the disease appeared were as fol- 
lows : — 

Male. Female. Total. 

Under 10 years .~ . . 16 10 2G 

Between 10 and 20 years 23 48 71 

Between 20 and 80 " 14 41 

Between 30 and 50 " 29 11 40 

Over 50 " 4^ 1 5 

99 84 183 

Hugon ^ has recently made a valuable addition to the literature of epi- 
lepsy in an excellent brochure upon the subject of etiology. 

He gives a table prepared by Martinet to show the proportion of cases 
beginning between the 10th and 20th years. 

Of 307 cases collected by Musset, there were 107 

" 68 " " Herpin, " 27 

" 83 " " Maisonneuve, there were 46 

" 306 " " Alegre, " 105 

" 106 " " Leuret, " 42 

" 230 '' '' Morean, " 76 

" 43 " " Danaut, " 26 

" 70 " " Delasiauve, *' 17 

" 75 " " Dussart, " 40 



^ In two of these cases there was an indication of syphilis. 
^ Eecherches sur les Causes de I'Epilepsie, etc., Paris, 1876. 



394 BULBAR DISEASES. 

It will therefore be seen that nearly half of all the cases begin before the 
twentieth year. Beau collected 273 cases, 43 of which began between the 
6th and 12th years; 49 between the 12th and 16th years; and 17 be- 
tween the 16th and 20th years. 

The attacks of early life are exceedingly irregular, and may begin as 
poorly developed paroxysms, which are by many classified under that 
most convenient term eclampsia, which oftentimes means nothing. A 
number of these attacks of an undefined type usually precede the genuine 
explosion of the real disease. 

In regard to sex, it may be said that Beaumes, Esquirol, and Moreau 
were of the opinion that the disease was more confined to women than 
men ; but on the other hand Celsus, Joseph Frank, Leuret, and Sandras, 
as well as Reynolds and others, take the opposite ground. From the 
number of cases I have collected and tabulated, I am inclined to adopt 
the same view as the latter. 

Of Hugon's^ cases, 32 in number, 25 were men, and 7 women. 

Professions seem to have very little to do with the production of the 
disease, if we except bar-tenders and liquor-dealers. 

In regard to the predisposing influences of temperament, climate, and 
season, it has been shown by Foville, Marce, Falret, and Delasiauve, that 
the nervous and sanguine temperaments predispose to the development of 
the disease. Maisonneuve found that of 65 cases, 25 were of a sanguine 
and 20 of a nervous temperament. Moreau considers that epilepsy is 
more frequent in winter than in summer, while others take the opposite 
view. AVhether climate affects the development of epilepsy, I am unable 
to say ; but, after very carefully conducted experiments in regard to the 
influence of temperature, I am prepared to state most decidedly that the 
attacks are much more frequent whenever there is a sudden change of 
weather. 

A writer in the Eevista-Sperimentale, of May or August, 1875, has 
given tables showing the influence of atmospheric changes, temperature, 
etc., upon the occurrence of attacks. Before that time I began a series of 
observations at the Epileptic Hospital. These, when compared with the 
accurately taken charts of temperature, barometric pressure, wind, etc., 
of the Health Department, conclusively prove the truth of the assertion I 
have just made. The number of attacks seemed to increase just at the 
change; and a very hot day, followed by a cool one, would show an in- 
crease of from ten to fifteen seizures among my patients during the cool 
day, and vice versa. 

The influence of heredity is more strongly shown in epilepsy than in 
any other nervous disease, except it may perhaps be progressive muscular, 
atrophy. In cases that I have seen the taint can be traced back for several 
generations either by epilepsy, neuralgia, insanity, or other nervous dis- 
eases. In one case the maternal grandfather died insane, the paternal 
grandfather died of apoplexy, the mother was living though subject to 

^ Op. cit., page 7. 



EPILEPSY. 395 

neuralgia, one brother had chorea, and the other had committed suicide 
in a fit of temporary insanity. Other examples are very much like this. 
Leuret^ found among 126 epileptic cases that there was a history of he- 
reditary epilepsy in seven cases. Beau's^ experience was equally interest- 
ing. Of 273 epileptics, thore was hereditary predisposition in 18 cases. 
Leech and Fox^ fixed the proportion of epileptics in whom hereditary 
taint was found at 36.8 per cent., which, as far as I can judge, is no exag- 
geration. Eeynolds* states that in the upper classes this hereditary pre- 
disposition exists to a much greater extent, but calls attention to the dif- 
ficulty of obtaining information. I have often been disappointed in get- 
ting reliable information, for this " skeleton in the closet " is kept closely 
guarded. I have been repeatedly astonished to find how strong this ele- 
ment is in the higher walks of life. In one family I find a long succes- 
sion of insane ancestors, idiot children, and dissolute progeny, which fully 
accounted for the transmission of the disease. It is a fact, however, that 
it does not follow that, because a parent has been epileptic, the off^^pring 
shall inherit the disease. Voisin found among 96 cases, 24 which fol- 
lowed hereditary alcoholism and phthisis. It is often due in the first in- 
stance to exciting causes, which, if removed, would probably be followed 
by disappearance of the disease. 

As to exciting causes, I may enumerate bad habits, excessive venery, 
syphilis, and uterine disease, which last I believe to he one of the most 
important of all causes in the epilepsy of ivomen. Fright, grief, anxiety, 
overwork, blows on the head, and other traumatisms, also enter extremely 
into the etiology of the disease ; and the disorders of digestion and the 
exanthematous disease often play a part in its causation. Onanism is a 
very common cause ; and of 24 male cases I have seen during the past 
year, this vice existed in 9. I may extract the following data from a paper 
in which I analyzed the chronic cases under treatment at the Hospital 
upon Blackwell's Island : — 

One-third of these patients suffered from intercurrent diseases ; 
two had advanced phthisis; several had nephritic disease; and a 
great many were anaemic. In regard to the complicating troubles, I 
find that twelve were subject to headache, two were hemiplegic (right), 
the epilepsy following the hemiplegia, two suffered from sclerosis 
(one locomotor ataxia, the other diffused cerebral sclerosis), and one was 
an idiot. 

"When we came to examine into the causes we found more difficulty 
than we anticipated. The intelligence and memory were much below par 
in all. Scarlatina and variola preceded the disease in two, syphilis in one. 
In nine the attacks were connected with menstrual irregularities and ute- 
rine disease (versions and flexions), two of these were masturbators (by 

1 EechercheP, sur I'Epilepsie, Arch. Gen. de Med., 1813. 

2 Archives Gen. de M^d., May, 1836. 

' Manchester Medical and Surgical Eeporter, quoted by Eeynolds. 
* Syst. of Med., vol. ii., p. 295. 



396 BULBAR DISEASES. 

confession), one of whom has been cured since the habit was broken. One 
case only was traumatic, four were congenital, and several gave absurd 
answers which were unsatisfactory. These are examples of chronic cases, 
and of course many are intractable. 

Morbid Anatomy and Pathology. — The variety of morbid 
appearances that have been found from time to time give no satisfactory 
explanation of the pathology of this disease, and we will not enter exten- 
sively into their discussion. Spicula of bone growing into the brain-sub- 
stance, thickened meninges, deformities, or depressions of the cranial 
bones, vascular anomalies, cysts, tuberculous deposits, softening, and a 
host of other changes have been observed. Some of these are important 
appearances which should not be dismissed too hurriedly. Undoubtedly 
the osseous changes are quite satisfactory causes. In three cases I found 
spiculse or nodules of bone growing into or pressing upon the cerebrum. 
In one of these the exostosis had attained a length of one inch, and varied 
from one-eighth to one-quarter of an inch in diameter. In other cases I 
have seen decided depressions of the parietal bones, which impinged to a 
great extent upon the brain-substance beneath. As far as the deep lesions 
go, nothing very conclusive has been found. Van-der-Kolk has dwelt 
at length upon the increased vascularity of the medulla and the softened 
patches sometimes present, but these changes are just as likely to be the 
results of the disease as they are to be the lesion which produces the con- 
vulsion. 

It seems likely, however, that the investigations of Cazauvieilh and 
Bouchet, Bourneville, Charcot, and Delasiauve in France, as well as 
those of Meynert in Germany, must throw some light upon the pathology 
of this puzzling disease. All of these observers found distinct induration 
of the cornu ammonis, or pes hippocampi. Cazauvieilh^ reports eighteen 
autopsies made at La Salpetriere. In nine of these one or both of the 
cornua ammonis were indurated, and at the same time there was indu- 
ration of the white matter of the hemispheres. Bouchet,^ in forty-three 
cases, found the same condition of affairs. He says, " La corne d'ammon 
est la partie cerebrale qui a le plus frequemment presente I'induration. 
Cette alteration a sou vent ete si frappante, et quelquefois si constants, 
que bien evidente neuf fois de suite pour quelques medecins assistants, 
elle leur a donne la conviction qu'elle representait exactement la cause 
pathologique de Tepilepsie." 

Bourneville observed this lesion five times out of thirty-four during the 
years 1866 — 1874. Meynert has repeatedly discovered induration of this 
part, and considers it a pathognomonic sign. In his examination the 
cornua ammonis were found atrophied, and appeared to be of a cartilagi- 
nous hardness, and had undergone a general alteration. 

Of ten autopsies that I have made, six presented this lesion, and in one 

1 Archiv. Gen. de Med., 3me Anne, 1825, i., ix., p. 510, et 4me Anne, 1827, i., v., 
p. 5. 

2 Sur I'Epilepsie (Annales Med. Paiychologiques, 1853, 1. v., p. 209). 



EPILEPSY. 3^7 

I found it to be uncomplicated. The other four cases presented nothing 
distinctive. In two the left hippocampus major was indurated, in three 
both were indurated, and in one the right was the seat of the same 
change. In one of these the extreme exterior part of the pes hippocam- 
pus was quite firm ; the little crenations or irregularities were more 
marked than in the healthy brain, as there had evidently been some 
atrophy with contraction. In one the gray matter just adjacent to the 
hippocampus major contained several indurated patches. In two cases 
the veins which skirt the inner edge of the corpora striata at the line of 
the velum interpositum, and receive branches from these bodies, were 
quite distended with blood, as were the vense galeni. The white matter 
in both anterior lobes was quite hard in three cases. In one case there 
were minute extravasations throughout the brain and in the medulla. 
In two cases there was effusion into the lateral ventricles. The cranial 
bones in one case were found to be considerably thickened. In all of the 
cases there were evidences of great meningeal hypersemia. In three of 
these cases I found microscopical disorganization of a granular charac- 
ter of the nerve-elements in the medulla. The vascular walls were thick- 
ened, and at certain points ruptured, the places of rupture having no 
special pathological relation as far as the nuclear involvement was con- 
cerned. 

In three cases which are not included in the ten referred to, I found 
osseous growths. Although this lesion of the cornua ammonis very rarely 
exists alone, it seems to be quite a constant morbid appearance, and it 
now remains for us to discover whether the condition is peculiar to 
epilepsy. 

Pfluger^ has made 300 autopsies at the Asylum of Ybbs, and in 25 
cases of epilepsy, sclerosis of the cornua ammonis was found. The entire 
number of epileptics was 43. The cases in which their appearance was 
found to be most perfectly shown were those which dated from infancy. 
In three cases the disease did not begin until after twenty. Of twenty- 
three in whom the attacks were frequent and violent, seventeen presented 
this lesion. He supposes the alteration to be due to malnutrition fol- 
lowing vascular trouble. 

Epilepsy is, without doubt, an organic affection, the established disease 
beginning, perhaps, after a peripheral irritation has been transmitted re- 
peatedly to the centres ; but after the disease is fairly developed, the con- 
vulsions are not necessarily produced by the excitement of such distal 
irritation ; for, as Nothnagel shows, in cases dependent upon a cicatrix 
the attacks are not, as a rule, excited only by irritation of the cic^rix. 
The clinical features of the disease prove the truth of this rule ; for, in 
any well-established case, gastric, uterine, or any other reflected irrita- 
tion may give rise to the seizures, or they may take place in an apparently 
spontaneous manner. We must, therefore, consider that epilepsy is a 

^ Allegem. Zeitschrift filer Pt^ych. and Eevue des. Sciences Med., 33, 1881, xxvi. 
p. 359. 



398 BULBAR DISEASES. 

disease of an organic character, expressing itself after either some distal 
or central stimulation in an irregular manner, or the result of both. 
That it is connected with central changes there is no reason to doubt ; 
though these changes are by no means uniform. 

The experiments of Brown-Sequard have thrown much light upon its 
pathology, though Nothuagel and others do not unreservedly accept his 
views. 

The experiments of Brown-Sequard were chiefly made upon guinea-pigs. 
He produced epilepsy by division of the trunk of the sciatic, internal pop- 
liteal and posterior roots of the nerves innervating the lower extremities, 
and by injury of various parts of the brain, the corpora quadrigemina, 
and cerebral peduncles. He also divided the cord at different points 
partially or completely, and shows that injury of the lower part of the cord 
seemed to have more to do with the subsequent epilepsy than when the 
upper part was mutilated. After these experiments, the first appearance 
of epilepsy occurred in from four to six weeks. The attacks were either 
spontaneous, or followed irritation of certain parts of the skin which 
were included in the so-called " epileptic or epileptigenous zone." This 
included the cheek, anterior part and side of the neckj and a portion of 
the back. This region became anaesthetic, and the hair usually fell out. 
Any irritation of this tract, such, for instance, as pinching, gave rise to 
an attack. Ultimately the anaesthesia diminished, and the attacks sub- 
sided, so that it was impossible to excite them. The " epileptic zone " 
corresponded to the side upon which the nerve or cord injury had taken 
place. 

Other forms of experimentation have produced convulsive attacks, or a 
condition resembling epilepsy. These were blows upon the back of the 
head (Westphall) ; irritation of the cortex-cerebri (Hitzig) ; ligation of 
the carotids and vertebral arteries (Cooper, Hall, Kussmaul, and Tenner) ; 
irritation of the peripheral sensory nerves (Nothnagel, Krauspe). The 
labors of these, as well as others, indubitably show that the epileptic attack 
is connected with cerebral ansemia,and the experimental production of this 
vascular state when irritation of peripheral sensory nerves has been made 
furnishes another link in the chain. 

The question of localization next arises. Brown-Sequard, Schiff, Rey. 
nolds, and Kussmaul and Tenner have all demonstrated that the medulla 
oblongata is the probable pathological seat of the disease. It has been 
proved by them that a so-called "convulsive centre" is here located, which, 
when excited, by reflex stimuli, gives rise to extensive spasms of both kinds 
of the voluntary muscles ; that whether the irritation comes ex chorda or 
ex cerebro, there is primary bulbar congestion, a cerebral anaemia, and a 
secondary cerebral congestion ; that such congestion follows reflex spasm 
of the cervical muscles, and that a condition of venous engorgement en- 
sues from pressure upon the large vessels of the neck. The pathology of 
the confirmed disease, as it has been generally considered heretofore, may 
be briefly stated as — 



EPILEPSY. 399 

A. The existence of a condition of reflex excitability of the medulla 
from a long-standing reflected irritation. 

B. An exciting impression transmitted from the periphery, or from a 
central part. 

C. The irritation of the vaso-motor centre (described by Dittmar and 
others) through congestion at the floor of the fourth ventricle. 

D. A secondary anseraia and hyperoeraia of the hemispheres. 
The production of symptoms probably due to — 

1. a. Anseraia of the brain ; 6. Consequential primary loss of conscious- 
ness, etc. 

2. Irritation of "convulsive centre," with tonic muscular contrac- 
tion. 

3. a. Irritation of nuclei of lower cranial nerves ; b. Consequential 
asphyxia. Contraction of muscles of neck, pressure upon vessels, etc., 
secondary stupor, clonic convulsions. 

Van-der-Kolk^ explains the tongue-biting as the result of irritation of 
the nuclei of the hypoglossal nerves. 

The observations of Hughlings Jackson^ and other modern observers 
throw much light upon the pathology, and give it a new and broader as- 
pect. The former proves " that those parts are wont to suSer first 
and most which serve in the voluntary (special) operations, and those last 
and least which serve in the more automatic (general operations)." 

Briefly to illustrate this, he quotes from an article in the Lancet^ 
demonstrating that the three points at which the convulsions often begin 
are : " (1) in the hand ; (2) in the face, in the tongue, or both ; (3) in the 
foot." 

This confirms the idea that the onset begins in the parts devoted more 
particularly to the execution of voluntary movements. He has been 
enabled to prove that in this manner the parts first attacked are those 
which are more commonly aflected in hemiplegia. He also calls attention 
to the phenomenon of aphasia, with epilepsy beginning in the right cheek. 

" Epilepsies," he says, " are the results of the second class of functional 
changes; they are, speaking briefly, discharging lesions. But there are 
many varieties of discharges. Defined from the paroxysm, an epilepsy 
is a sudden, excessive, and rapid discharge of gray matter of some part 
of the brain ; it is a local discharge. To define it from the functional 
alteration, we say there is in a case of epilepsy, gray matter which is so 
abnormally nourished that it occasionally reaches very high tension and 
very unstable equilibrium, and, therefore, occasionally explodes. . . . 
It will be observed that the discharging lesion of epilepsy is supposed to 
be 2^ permanent lesion ; there is gray matter which, since it is permanently 
under conditions of abnormal nutrition, is permanently abnormal in 
function. That this permanent abnormality is a varying state, has been 
said ; it has been remarked that the gray matter occasionally reaches 

^ Brain and Spinal Cord, Sydenham Trans. 
^ W. Riding Reports, vol. iii. p. 315, et seq. 



403 BULBAR DISEASES. 

high tension, and, therefore, occasionally discharges (or is discharged). 
There are waves of stability and instability. It follows from this 
that the first fit is supposed to be a discharge of a part which has for 
some time before been in a state of malnutrition ; and a still further 
inference is that such ' causes ' of epilepsies as fright are only determin- 
ing causes of the first explosion. Many of the premonitory symptoms of 
a first attack are probably results of slight discharges ; they are minia- 
ture fits.^' 

That irritation of the auditory apparatus may give rise to a variety of 
epilepsy there can be no doubt, but such cases I believe to be rare. 
Brown-Sequard^ states that Mr. Hinton, an English surgeon, has reported 
several where, after death, no lesion was discovered, except evidences of 
disease of the middle ear. My friend Dr. Roosa tells me that out of five 
or six thousand cases of aural disease he has seen, he does not remember 
but one of this kind : — This patient was under my observation. 

John W. P , aged 15 years and 6 months, a stout and apparently 

healthy boy, well nourished, and presenting no external evidences of dis- 
ease ; family history good. His mother stated that he had always been 
a rather dull boy, and that at school he was generally behind in his stu- 
dies, and did not seem to learn easily, and when sent on errands, he was 
unreliable and forgetful. There is no history of injury or sudden fright, 
nor has there been any known predisposing or exciting cause; but at the 
age of eight years he had a severe attack of scarlatina, which left him 
with a remaining otitis, most severe on the right side, and resulting in a 
profuse discharge of pus, which still continues in a modified degree, but 
is not so excessive as it was a month ago. About six weeks ago he began 
to syringe his ears wdth a carbolic acid solution,. which had the effect of 
removing a large mass of what was probably inspissated pus ; and his 
hearing, which had before been quite defective, became greatly improved, 
and he no longer complained of various subjective noises, such as buzzing 
and roaring. When the quantity of discharge was diminished, his ears 
became painful, and pressure on the mastoid processes caused much suf- 
fering. Ever since the scarlatina he has had frontal and occipital head- 
ache, which is alway8 constant. About a month ago he had his first 
epileptiform attack, and this occuried about noon one day when he was 
using his syringe. Without warning, he suddenly fell to the floor, be- 
came convulsed, and in a few minutes recovered, and did not fall asleep ; 
but a semi-unconscious state, however, supervened. 

The next attack came on four days after, at 3 P. M. While he was 
chatting with a friend, he suddenly stopped talking, and fell. This 
attack was much more violent than the first one. They now become 
more and more frequent, until about two weeks ago, when on one occa- 
sion he had fifteen during twenty-four hours. Since then he has not had 
so many, having had between one and five attacks every day but one, 
which was the only day he missed the attack since the commencement. 
During some of the attacks he is very violent, while in others not so 
much so. His appetite has been irregular for some time past. An ex- 
amination made by Dr. Baldwin, House-physician of the Epileptic and 

1 Central Nervous System, p. 98, and Gaz. MeJ. de Paris, 1842, p. 25. 



EPILEPSY. 401 

Paralytic Hospital, and myself, revealed tenderness on pressure over 
mastoid processes, but mostly on the right side. He has had no definite 
aura, but peculiar sensations which he cannot describe, preceding his 
attacks. He complains of vertigo and nausea, and muscular weakness 
after the slightest exertion. He invariably returns to consciousness almost 
immediately after the attack, attempts to rise and w^alk, but is usually 
quite feeble. 

Examination of Ears. — R. : Discharge scanty, thin, and sero-purulent ; 
and, on examination, the membranum tympani is found absent. The 
tick of a watch is heard only when the watch is pressed against the ear ; 
a roaring sound is always present. 

L. : The same examination shows more or less congestion of the tym- 
panum, with evident signs of otitis media ; but there is not so much pain 
on this side, and the hearing is better, the ticking of the watch being 
heard at three inches. 

Patient has complained lately of deep, severe pain in the frontal, but 
extending back to the occipital region. With this pain there is dizziness, 
especially when he stands, thus making it difficult for him to preserve 
his equilibrium, which is strikingly shown by his irregular movements. 
When sitting up in bed, he complains that objects move up and down, 
and not horizontally, as we should expect to find in ordinary auditory 
vertigo ; and a very interesting and peculiar symptom are the movements 
he makes to preserve his relation with surrounding objects, his body 
moving up and down, and his head swaying strangely. He is very sus- 
ceptible to noises and bright lights, either being capable of inducing a 
spasm at times. Vomiting from an empty stomach is occasional, with 
dilatation of pupils. The vision of right eye is at times entirely lost, but 
at others is unimpaired. Muscle volitantes are frequently complained of. 
Examination of urine affords negative results. 

Observations during an attach or convulsion, ivhich occurs at no regular 
intervals, but is a constant result of irritation of the internal auditory ajjjya- 
ratus : — 

Ear syringed at 9.55 A. M. Patient calm, and not at all nervous ; 
skin of normal hue; pulse regular; temperature normal; pupils some- 
what dilated. He passed a good night, and suffered but little pain, 
though his vertigo was still troublesome. He was placed upon a bed, 
and the point of an ordinary two-ounce syringe, filled with tepid water, 
was inserted in the external meatus of the right ear, and the contents 
gradually expelled. This caused some pain and dizziness, which increased 
as more water was injected ; and when one ounce had been thrown in, 
the patient became suddenly unconscious, and the head was drawn from 
one side to the other by rapid clonic contractions of the muscles of the 
neck, and almost at the same time the convulsion became general, the 
muscles of the back being extensively involved. 

About five seconds after this, there were clonic spasms of the muscles 
of the jaw, so that the patient snapped his teeth, and, at the same time, 
forcibly inspired, giving vent to a peculiar noise which might be easily 
compared, by a person of lively imagination, to the bark of a dog. 

This paroxysm lasted two minutes, and during its continuance the 
pupils were widely dilated. The patient remained unconscious; but 
there was neither pallor nor suffusion of the face. Thirty seconds after- 
wards, a period of muscular relaxation succeeded, a fresh attack followed, 
26 



4r02 BULBAR DISEASES. 

during wliicli there was more marked opisthotonos, much more noise, but 
no frothing at the mouth. Pupils still dilated, though perhaps not so 
much so as at first, while the skin was slightly suffused ; but there was 
no duskiness. Duration, one and a half minute. Ten o'clock and thirty 
seconds, after slight relaxation and subsidence of movements, the lateral 
jactitation of the head again began ; and at ten o'clock and one minute a 
violent accession of clonic, and afterwards tonic spasms made their ap- 
pearance. The eyeballs had throughout been uncovered, and at first 
were stationary and immovable, or almost so ; but now they were agitated 
by nystagmatic movements, and the pupils were dilated. This paroxysm 
lasted but thirty seconds. At ten o'clock and three minutes there was 
another seizure, during which the left sterno-cleido-mastoideus was in- 
volved in a prolonged tonic contraction. The pupils now partially re- 
turned to their normal condition, which was one of slight dilatation ; and 
at ten o'clock and four minutes the patient became semi-conscious, answered 
questions in monosyllables, and after a few minutes recovered entirely. 
The pulse suffered no variation, except, perhaps, after two minutes had 
elapsed from the beginning of the seizure, when it seemed to increase in 
volume, and perhaps slightly in rapidity. There was an entire absence 
of any external evidence of asphyxia, which is so marked in the more 
familiar form of epilepsy. 

I have ascertained that the convulsions may be precipitated by simply 
blowing into the external auditory meatus. 

Diagnosis. — Epileptic attacks may be mistaken for the convulsions 
of Bright's disease, infantile convulsions, hysteria, alcoholism, opium 
poisoning, syncope, and softening, and the disease is occasionally simu- 
lated by malingerers and others. I may briefly dispose of the above : 

1. Ursemic convulsions are generally preceded by drowsiness or coma, 
deliriuni and stertor. The limbs may be oedematous, and the urine con- 
tain albumen. 

2. Infantile convulsions from worms, dentition and other eccentric 
causes, are usually attended by a febrile condition. The convulsions are 
of short duration, and are characterized by complete loss of consciousness. 
The discovery and removal of the cause usually eflfect a disappearance of 
the attacks. 

3. Hysteria (See article Hystero-Epilepsy.) 

4. Alcoholism and opium poisoning are characterized by a more pro- 
tracted stage of unconsciousness, and by a contraction of the pupils in the 
latter. 

5. Fainting attacks may resemble the petit-mal, but there are no 
spasms, and the pulse is feeble. 

6. Softening and other organic states give rise to convulsions, but the 
accompanying symptoms should enable the observer to make the diagno- 
sis in every instance. 

Simulated convulsions may deceive a careless person, but the normal 
condition of the pupil, and the eagerness of the individual to play his 
part perfectly which he does not do, lead to the detection of the imposi- 
tion ; and the excessive pallor of the first stage can never be simulated. 



EPILEPSY. 403 

^ Dr. Carlos Macdonald reports the case of a patient who feigned epilepsy 
and who was known as Clegg the " dummy chucker." CJegg was a 
criminal, and feigned epilepsy so successfully that he escaped hard w^ork 
and was generally regarded by a number of prison physicians as an ob- 
ject of sympathy. He submitted to all manner of painful tests, and upon 
one occasion he actually fell twenty or thirty feet in one of his shammed 
attacks. Dr. Macdonald, however, was suspicious and watched him very 
carefully and finally compelled the man to confess. In his pretended 
paroxysm the hands were closed but the thumbs were not so closed, nor 
were they flexed at any time, and the sphincters were never relaxed. 
His facial expression at times betrayed him when he was closely watched. 
There was no lividity beneath his nails. These indications, together 
with the patient's manner, which was ostentatious, so far as showing his 
scars and alluding to his feelings was concerned, convinced Dr. Macdon- 
ald of the deception. 

The syphilitic form of the disease resembles much the ordinary variety, 
but in some instances it is of the greatest importance to distinguish its 
specific nature, as of course the treatment is entirely different from that 
employed in the non-specific disease. Buzzard, who has given us an 
admirable little work on the syphilitic neuroses, lays great stress upon the 
necessity of recognizing the variety of pain as a differential symptom. 

"If pain in the head be associated with convulsive attacks," he says, 
" it generally precedes the attack in syphilitic convulsions, and is often 

localized in one particular spot In simple epilepsy (if it be 

present) it almost always follows the fit, is diffused over the forehead, and 
is at no time a strongly marked symptom." The age of the patient, and 
the time from which the attacks date, are also of great importance in this 
connection. It is not probable that syphilitic epilepsy would begin early 
in life, or, at least, before puberty, but simple epilepsy dates from early 
childhood. 

Prognosis. — The duration of the disease has much to do with the 
prognosis, and the mode of origin, form of expression, and complicating 
conditions must all be considered before an opinion is given. If the 
disease be of idiopathic origin, or if it be due to violence, i. e. injuries to 
the head, the prognosis is bad. If it be due to eccentric causes or syphilis, 
there is reason to be hopeful. Hereditary predisposition is an obstacle in 
our path which sometimes blocks the way to a cure. I have found that 
the j)etit-mal is also less amenable to treatment than the severe form, and 
that it is pretty sure to produce an impaired mental condition. 

Eeynolds thinks that the attacks which recur rapidly are more amena- 
ble than those which take place at long intervals, but this has not been 
my experience. If there be any considerable congenital lack of intelli- 
gence the case may be considered as incurable. The unfavorable condi- 
tions are the occurrence of a great many attacks in a short space of time, 
the biting of the tongue, and a condition which has been known as the 

^ American Journal of Insanity, July, 1880. 



404 BULBAR DISEASES. 

"status epilepticus," in which the patient lapses into a comatose state, 
and there are a number of fits in close succession. Death in the actual 
fit is not common, and I know of but six fatal cases : five from the dis- 
ease, and one from falling upon a sharp iron point which penetrated the 
orbit. 

Treatment. — Before entering upon the discussion of particular 
modes of treatment, I desire again to refer to certain etiological facts 
which bear to a great extent upon the selection of remedies. 

I may be pardoned for calling attention to practical points which 
may appear unimportant to some ; but an experience gained from the 
management of a great many cases teaches me that they are to be care- 
fully considered in selecting a plan of treatment. These simple indica- 
tions, I am convinced, are too often overlooked even by painstaking and 
careful medical men. I allude to the necessity for discovering the excit- 
ing cause. I am every day made to feel that the idiopathic cases do not 
form so large a proportion as they were once thought to. With .this be- 
lief I am satisfied that empiricism and routine management are bad 
methods. Any one who examines all his cases thoroughly will recognize 
the delicate shades in epilepsy, variations which are exhibited in other 
diseases presenting more pronounced and better defined symptoms ; con- 
sequently there are evidences of pathological action, which are not always 
grouped alike, and therefore all cases are not to be treated in the same 
manner. I ascribe the moderate success I have had in the management 
of this disease to the recognition of these differences. 

Kot only may obstinate epilepsy result from masturbation, but it may 
be due to many diseases of women, and it is produced by eccentric ■ 
irritations of various kinds, or by centric irritation, such as maybe asso- 
ciated with toxaemia. 

Sir Charles Locock ^ called attention to many cases he had treated 
where uterine irritation was the exciting cause ; and I think others have 
had the same experience. In one of Locock's cases the patient was 
affected particularly at the menstrual periods. 

Some of these peripheral causes are curious in the extreme. Through 
the kindness of Dr. Gibney, of New York, I was enabled to see a child 
who had accidentally injured her ear with her parasol, the brass tip of 
which remained for some time imbedded in the external auditory meatus. 
As a result, convulsions of an epileptic character were caused, and it was 
not until some time afterward that the foreign body was discovered and 
removed. In another case I treated, the epilepsy was unmistakably due 
to a bad habit the woman had of wearing a number of heavy garments 
about her hips, which produced some uterine change. When this condi- 
tion of afifairs was noticed, and the skirts removed, she immediately re- 
covered. At the root of many epilepsies, as well as other neuroses, are 
reflex causes — the starting-point being the organs of digestion, or those 
contained in the pelvis. Of course the varieties of epilepsy of an idio- 

1 Med. Times and Gazette, May 23, 1853. 



EPILEPSY. 405 

pathic nature, or those caused by traumatism or organic disease, will defy 
the best efforts of the physicians. 

In prescribing for our patient there are five indications to observe : — 

1. Kemoval of exciting causes, if possible. 

2. The diminution of exaggerated reflex susceptibility of the medulla. 

3. Equalization of cranial circulation. 

4. Abortion of paroxysms. 

5. Improvement of general condition. 

For the accomplishment of these, it is imperative that a judicious and 
discreet selection of drugs should be made ; and among those which are 
the most effective I may mention : — 

The Bromides : sodium, potassium, ammonium, calcium, lithium, iron 
Chloral hydrate. Strychnine. Arsenic. 

Belladonna. Ergot. Amyl-nitrite. 

Digitalis. Mercury. Tri-nitro-glycerin. 

Cod-liver oil. 

I have not classified these remedies, as it is unnecessary to do so ; but 
will now say a word in regard to their usefulness. 

No one drug can be declared a specific, as I am sorry to see has been 
done ; and we must not be too eager to accept the sanguine results of 
certain over-enthusiastic authorities, and be governed thereby. I allude 
more especially to the almost universal use of the bromides to the exclu- 
sion of everything else, and also to their employment in quantities which 
often ruin the patients, or, at any rate, produce a condition of diminished 
vitality, which is inconsistent with any hope of success. Kadcliffe's^ idea 
in this respect is a good one : " There is reason to believe that the thera- 
peutics of convulsion must be based upon the notion that vital power has 
to be reinforced, and not upon the contrary opinion." AYhat the proper 
dose is has not been clearly settled by any one. There are neurologists 
Avho believe in toxic doses, and there are others who prescribe quantities 
which are almost small enough to be inert. In England it has been the 
custom to prefer the small doses. I have seen the prescription of a 
very distinguished general practitioner, who some years ago thought five 
grains of the bromide of potassium a suflicient dose ; but this has now 
changed. Ringer^ recommends from 30 to 60 grains in the day ; Rad- 
cliffe,' 45 grains ; Russell Reynolds,' 30 to 90 grains ; Bartholow,^ 30 
to 240 

Handfield Jones'^ remarks that there is a great difference in the tole- 
rance of individuals in regard to the bromides — some persons not being 
able to stand five grains, while others will not be affected by doses of less 
than forty grains. 

^ Pain, Epilepsy, and Paralysis, p. 215. 

- Handbook of Therapeutics, p. 92. 

2 Op. cit., p. 202. 

^ Op. cit., p. 323, vol. ii. 

^ Materia Medica and Therapeutics, p. 371. 

^ Functional Xervous Diseases, p. 325. 



406 BULBAR DISEASES. 

My own experience has taught me that the best effect can be gained by 
the repeated administration of sixty grains in the twenty-four hours. 
The larger doses produce rapid bromism, while the medium dose seems to 
be better appropriated, but will do just as much mischief in the way of 
bromism as the larger one, if given for a length of time. My records 
show me that the average time for development of symptoms of this kind 
is about three months, while anaesthesia of the fauces is produced in a few 
weeks, or even a much shorter time ; and I agree with others that it is 
necessary to produce this condition before we can say that the medicine 
has produced its physiological effect. But when once reached, the further 
toxic action of the drug is deleterious instead of beneficial. Brown- 
Sequard considers the appearance of acne to be an indication that the 
medicine has begun to do its work, in which opinion he is joined by Dr. 
Putnam- Jacobi.^ Voisin^ considers the " point of saturation to be indi- 
cated by the ansesthesia of the pharynx and nares, so that in one case 
nausea is not produced by titillation with a spoon, and in the other sneez- 
ing and weeping do not follow the introduction of a straw into the nasal 
cavity." I should consider the latter a rather severe test. According to 
Danton,^ the bromides act as vascular medicaments, diminishing excito- 
motor power. They act on the anstriped muscular fibre, producing local 
ansemia, and moderating excitation resulting from temporary or perma- 
nent congestion. " They are agents that pass very rapidly into the blood 
(Ringer),^ and consequently their effects are very immediate, and they 
accumulate till the point of saturation is reached before they are elimi- 
nated in anything like considerable amounts." We are all aware that 
repeated and large doses of these drugs are followed by a most disagree- 
able and pernicious state of affairs. Voisin^ has referred to two forms of 
bromism, which he has divided, into the slow and rapid. In the first the 
complexion becomes muddy, the eyes sunken, sight and hearing poor, and 
memory obscure. The patient cannot write, and cannot express himself, 
as he forgets words ; there is tremulousness. In the other variety of the 
slow form there is dementia, or delirium with manical outbursts. Ataxia 
is also a feature of this variety. In the rapid form — that with which we 
are most familiar — somnolence, headache, uncertain walk, difficulty o 
speech, loss of expression, " fishiness " of the eyes, drooling of saliva, etc. 
etc., are the ordinary symptoms. 

Various grades of toxaemia, or even a state which Voisin calls the " ca- 
chexie bromique," and which terminates in a typhoid condition, may result 
from a reckless use of this drug. 

As regards the variety of bromide, I think the sodic is the most reliable 
and stable, the potassic salt varying very much in strength. The others 

^ Oral communication before Am. Neurological Association. 

^ Voisin, Archiv. cle Medecine, Jan. 1873, 

^ Danton, These de Paris, 1874. 

* Op. cit. p. 91. 

5 Voisin, Archiv. de Medecine, Jan. 1873. 



EPILEPSY/ 



407 



either have a tendency to deliquesce, or are expensive. It will be advis- 
able to keep the solution in a tight-stoppered bottle, and have fresh quan- 
tities put up constantly, as it is very apt to undergo changes — in which 
the bromine is evolved. And now a word regarding the time of adminis- 
tration. It has been shown repeatedly that these salts are much better 
absorbed when the stomach is empty. I have found also that a heavy 
dose at night is apt to do more good than if the amount prescribed is 
equally divided up through the day. In a great many patients I have 
found the attacks to occur at the waking hour, and I suppose this is due 
to the sudden change in the cerebral circulation. A mild diffusive 
stimulant has overcome this, and in many cases warded off the attack. I 
direct my patients who have their convulsion at this time to keep a glass 
or a small quantity of spts. ammonise aromaticus near at hand, to be 
taken before rising. Cold douches to the head are valuable. If the at- 
tacks be irregular, it will be found necessary to divide the dose. 

Analysis of Eleven Cases of Epilepsy. 
S. B. — Sodic bromide. P. B. — Potassic bromide. 



Sex and 
age. 



Duration of 
disease. 



Average 

No. of 

attacks 

before 

treatment. 



Maximum 
dose. 



Minimum 
dose 



Diminu- 
tion. 



Eemarks. 



Male, 
Male, 



Male, 25 

Female, 2 

Female, 18 
Male 18 
Female, 11 

Female, 17 
Male, 20 
Male, 13 



Since birth 
Two years 

One year 

18 months 

One year 
Five years 
Five years 



Several 

months 
19 years 

Two years 



1-2 weekly 
1-2 weekly 



S. B. gr. XX. S.B. gr. xv. 
t. i. d. t. i. d 

S. B. gr. XV, 



1 or more S. B. xxv., 
n week, P. B. gr. 
sometimes xxx. 
many in 
day 

1-2 weekly, Very small 
sometimes j doses. 
3 in a day 
1 in week 'S. B. gr.xxx 



4 in week 
2-3 in week 



S. B.-r. XV. 
S.B. gr. XX. 



Sometimes S. B. gr. xv, 
4-5 daily 



2-3 weekly 
3 weekly 



Male, 25 11 years il in 2 weeks 



S.B. gr.xl. 
S. B. gr.xxv 

S. B. gr. XX. 



S. B. gr. ij. 



Gr. XX. 



S. B. gr. XV. 



S. B. gr. XV, 
S. B. gr. XV. 



2 in 8 weeks 
1 in 20 wk's 



None in 8 
weeks. 



None in 8 
weeks. 

None in 4 

weeks. 
None from 
5 weeks. 
1 in 5 w'ks 



None after 
treatment. 
No fits for 
2 weeks. 
I in 3 w'ks. 



1 in 5 w'ks, 



Weak intellect. 

Disease followed 
sunstroke ; treat- 
ment lasted three 
months. 
Hard drinker, 

feeble intellect '. 

potassium salt 

intrt. 

Fits followed den- 
tition; rickety 
constitution. 

Tuberculous dis- 
ease. 

No affection of 
intellect. 

Followed a blow ; 
subject to head- 
ache. 

Has bitten tongue 

No aura. 

Well developed 
disease, facies 
epilepticawell 
marked. 

No fits since be- 
ginning of treat- 
ment. 



By this table it will be seen that from fifteen to twenty grains of the 
sodic salt were required to immediately decrease the number of attacks. 

The treatment of the disease in women should be directed as well to the 
pelvic organs. It will be found that the bromides will markedly affect 
the flow, and relieve the pain or uneasiness which is connected with the 



408 BULBAR DISEASES. 

menstrual period. Locally I have found that cold applied for a few 
minutes daily over the ovaries will modify the attacks should they be 
connected with irritation of any of the pelvic viscera. The progress of 
the disease should be soon modified by the doses I have recommended; 
and it will be seen by the table condensed from that prepared by Dr. 
Hollis,^ that even smaller doses modified or cured the majority of the 
cases he cites. At the Epileptic and Paralytic Hospital, where most of 
the cases are the very worst that can be collected as regards chronicity, I 
find that sixty grains a day will cut short the attacks of a great many pa- 
tients, and I have cured a number of private patients by this method. 
Dr.. Hollis' cases were not selected, and are evidently hospital patients, 
like my own. 

On succeeding pages will be found two tables. In one are tabulated the 
interesting features of twelve cases of epilepsy. They are old hospital 
patients, and had applied for admission after outside treatment had been 
exhausted. Even here the bromides, in the doses I have given, seem to 
do much for the sufferers. Head-injury and actual insanity make the 
prognosis as bad as it well can be, and treatment is simply palliative. 
Large doses have aggravated many of those cases. 

The other observations are selected from my note-book, and are illus- 
trative of the efficacy of the dose I have advocated. Bromism occurred 
in spite of all I could do in most of them, though it was a mild form and 
under control. The patients were all of the better class, and of course had 
all the advantages of comfortable homes, attentive friends, substantial 
food and good air, although many of them were inclined to over eating, as 
in fact all epileptics are. In this respect there is an advantage in favor of 
the poorer patients, who cannot obtain rich food. 

And now regarding the large doses. If the idea is thoroughly to ruin 
the patient's health, enfeeble his mind, or perhaps drive him to an asylum, 
the toxic administration may be indulged in. It is very true that some- 
times a rapid restoration may be brought about by ''iron and quinine;" 
but there are many cases where the recovery is not quite so complete as 
one could wish for. Memory is enfeebled, and there is a cachexia which 
remains for an indefinite time. A darker side of the picture is not always 
displayed when brilliant results are detailed. This is the list of 
demented and those that have died. Dr. Janeway was present at the 
autopsies of two patients who died brominized, for certainly the examina- 
tion disclosed no other cause of death. I myself have seen several 
demented cases, and I have no doubt others could tell the same story. I 
have used the bromides in combination with chloral hydrate, and have 
obtained the most excellent effects. Such good results as diminished 
condition of stupor and eruptiqn, follow the administration of equal parts 
of chl6ral and the bromide of sodium. The bromides of ammonium 
and sodium with chloral as recommended by the N. Y. Therapeutical 
Society, may be employed. 

1 British Medical Journal, July 1, 1876, p. 4. 



EPILEPSY. 



409 





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EPILEPSY. 411 

Belladonna and its alkaloids are of great value when the seizures occur 
in the daytime, or are of the variety known as petit mal. I have injected 
the sulphate of atropia in i^ gr. doses beneath the skin at the back of 
the neck with good effect, and have used it in the manner directed by 
Trousseau. In either way it should be administered until dryness of the 
throat is obtained, and should be given a patient trial. The property 
possessed by belladonna of blunting reflex susceptibility assures it a great 
advantage over other methods of treatment, when there are centres of 
irritation such as in gastric epilepsy. 

In ergot we have a remedy which controls the cranial circulation much 
more readily than any drug with which I am acquainted. As the object 
is to diminish the congestion at the floor of the fourth ventricle, its com- 
bination with the bromides greatly increases the action of the latter. 
Ergotin may be given alone in the form of Bonj can's capsules. 

To TyrrelP belongs the credit of suggesting strychnine. He believes 
that this remedy controls excitation of the medulla oblongata. In one 
individual who averaged fifty-one attacks in a month, the number was 
reduced by the strychnine to eleven in two years. Handfield Jones does 
not favor the remedy, nor do others, although it has advocates in this 
country. In small doses it certainly does good ; but I have found that in 
larger doses than tjV gr., ter in die, it rather aggravates the disease. 

Arsenic is excellent, both for its anti-periodic and alterative action, and 
as an agent to relieve the acne. Clemens, of Frankfort, has lately advo- 
cated the bromide of arsenic, but in such small doses as to seem useless. 
He claims for it remarkable virtue when the disease depends upon idiocy, 
and appears in patients ^vdth deformity of the skull. He reports two 
cures. 

Dr. Hughes Bennet" reports the results of the bromide treatment in 
one hundred cases of epilepsy. In over sixty per cent, of the cases decided 
benefit resulted, the attacks being prevented or aborted. In about thirty- 
five per cent, there was bromism, and the remainder suffered from general 
enfeeblement of mind or body, without much benefit so far as the relief 
of the disease was concerned. 

Dr. Bennet's method of administration consisted of doses of thirty 
grains of the bromides of potassium and ammonium, in the proportion of 
two parts of the former to one of the latter, given with aromatic spirits 
of ammonia and water. The dose was always given when the stomach 
was empty. After two or three months the dose was diminished. 

-Where there is an irregularity of heart action, sluggish circulation, 
blueness or duskiness of the skin, I think digitalis is indicated ; in fact, I 
generally use it in every chronic case. It is a drug well tolerated by 
epileptics, who can take it in surprisingly large doses. 

An agent has been lately given to the j^rofession which seemed all that 

^ Med, Times and Gazette, May and August, 1S67. 
- Br. Med. Journal, June 7, 1873, and Journal of 2servous and Mental Diseases, 
October, 1S79, p. 770. 



412 BULBAR DISEASES. 

was needed at first, but which I am convinced is very much over-estima- 
ted, except as an abortant. I speak of the amyl nitrite. Drs. Weir Mit- 
chell, Zeigler, and Alexander McBride, as well as several foreign writers, 
have praised it, and several cures have been reported. In epilepsy there 
seems to be a "habit (if I may use the expression) or tendency to period- 
icity. Amyl is well adapted to stop this, as is any other remedy of the 
same class. Crichton Browne alludes to the efiects of this drug upon the 
status epilepticus. His patient had had a great succession of fits, and was 
at the point of death ; the pupils were contracted to an intense degree, 
pulse 116, temperature 102°, with stertorous breathing. Voluntary 
movements and yawning were caused by inhalation of the amyl nitrite, 
and the patient subsequently raised his head, looked about him, and re- 
covered. Dr. Browne relates ten other cases which were seen with Dr 
Mierson. 

Dr. C. Stecketec^ draws the following conclusions in regard to the action 
of this drug in epilepsy : — 

" It exerts an important influence where the epilepsy is due to or con- 
nected with cerebral ansemia, for the reason that it ' anticipates the attack 
when there are prodromata; cuts oflTthe attack when it appears; relieves 
symptoms due to interrupted innervation after the attack ; and the attacks 
become less frequent.'" He also considers it injurious where the attacks 
are due to cerebral hyper^emia, for the reason that they last longer and 
become more frequent, and when either maniacal or convulsive, increase 
in intensity. 

]My own experience with amyl nitrite has clearly settled in my mind 
the fact that it has great virtues in cutting short or averting attacks, but 
that it has no permanent influence. Whether we can or cannot make the 
delicate distinctions of Dr. Steketec, future clinical experiences I think 
must decide. Those who have used it say that it does good in a very lim- 
ited number of cases; and it is a difficult task to decide which are to be 
benefited. I have tried it in every grade of epilepsy, and find in some of 
the worst cases, where the fits occur all through the day with very slight 
intervals, and even where there is time enough to be prepared, that it is 
often of no avail. It may be given inclosed in the little glass capsules 
invented by Dr. McBride, of New York, for hospital use, and for patients 
who are not intelligent, in alcoholic solution. 

^ Bourneville and d' Oilier have used the bromide of ethyl in epilepsy 
and hysteria, and have found that when it was inhaled during the tonic 
phase of the attack, it produced an abortion of the subsequent stages of 
the attack. My experience with the new anaesthetic given in solution 
in epilepsy was not encouraging — but it may be given by inhalation in 
place of amyl. 

^ Berland has used tartar emetic in doses sufficient to produce vomiting 

1 Abstract of thesis in Chicago Journal of Nervous and Menta! Disease, April, 
1874. p. 260. 

^ Gaz. Med. de Paris, :^ro. 35, 1880. ^ ji^gge de Paris, 1880. 



EPILEPSY. 413 

with marked relief in cases of violent convulsive chorea, and it seems 
worthy of trial in congestive epilepsy. 

I may be pardoned for bringing another remedy to the notice of the 
profession, and one that has never been used for this purpose. I allude 
to tri-nitro- glycerine. Its reputation is almost enough to intimidate the 
patient, but it is as powerful a medicinal agent as it is an explosive. The 
tenth part of a drop touched to the tongue is sufficient in a space of time 
which is almost inappreciable to produce a rapid cerebral hypersemia. 
The face is flushed, the eyes become bright, and the temporal vessels 
throb, while at the same time there are marked sensations of fulness. It 
produces more lasting congestion than does amyl nitrite, is much safer, and 
I have found it to act better as an abortant than the latter. Any good 
pharmacist can prepare a solution containing one drop to ten of alcohol. 
This can be further diluted, so that ten drops of alcohol shall contain one- 
tenth of a drop of the nitro-glycerine solution. It may be kept safe in 
this way, for alcohol prevents its explosion. A dose of from a tenth to 
one drop of the decimal solution is sufficient in the majority of cases. 

Last of all, it seems almost unnecessary for me to direct attention to 
that most familiar remedy, cod-liver oil, which is so valuable in all ner- 
vous diseases. Anstie treated a number of cases by cod-liver oil alone, 
and cured seven out of twenty patients put upon this plan of treatment. 
In all cases I am convinced that it is a valuable remedy which is not appre- 
ciated as it should be. I have witnessed its great virtues when the bro- 
mide cachexia was profound, and believe that it should always be used in 
delicate subjects. Picrotoxin, a remedy recently brought forward, I have 
tried, and consider valueless. 

The subjects of diet and personal habits are very important ones — par- 
ticularly as the stomach is so often the seat of irritations which are trans- 
mitted to the over-active centres. Beyond the question of over-eating, it 
has been found that a vegetable diet is better suited to this class of 
patients. Mierson, in one of the volumes of the West Biding Reports, 
publishes cases, and makes comparisons between those epileptics placed 
upon a meat and those upon a vegetable diet. The results j)ointed to the 
superiority of the latter. As the greater number of epileptics have 
inordinate appetites, the diet should be strictly regulated. 

It is a good plan, I think, to combine the remedies I have alluded to ; 
and I take the liberty of presenting a prescription I have used for several 
years : — 

R. Strychnine sulph. gr. j. 
n. ext. ergot^e, ^iss. 
Sol. potass, arsenit. '^i]. 
Sodii bromidi, jiss. 
Tr. digitalis, 5iij- 
AquDe menth. pip. ad ^iv. — M. 
Sig. — A teaspoonful before eating, in a half tumblerful of water 



414 BULBAR DISEASES. 

If the attacks be the form known as petit mal, I think either ergot or 
belladonna are our best agents. With either form of treatment it may be 
found often necessary to use auxiliary general treatment. The syrup of 
the combined phosphates, or the syrup of the lacto-phosphate of lime, is 
a good adjunct; and salt baths, cold head douches, regular food, early 
hours, and the breaking off of bad habits, will often cure the disease, even 
when it has lasted many years. 

As a last resort, should continued medication prove useless, the actual 
cautery or a deep seton at the back of the neck will occasionally arrest 
these bad cases. 

A variety of other remedies have been suggested (and the list of drugs 
alone would fill several pages such as this), but as most of them have 
been found inefficacious, I do not think it worth while to further weary 
the patience of my readers. Galvanism I find to have but little value. 



BULBAR PARALYSIS. 

Synonyms. — Glosso-labio-laryngeal paralysis (Hammond) ; Glosso- 
laryngeal paralysis (Trousseau) ; Progressive bulbar paralysis (Erb). 

In the year 1841 Duchenne^ first called attention to a peculiar group 
of symptoms which were connected with progressive degeneration of the 
medulla oblongata ; and some years later Trousseau ^ noticed it in his ad- 
mirable lectures, and presented several cases reported by Davaine,^ long 
before Duchenne's observations were published, but which were before 
considered to be examples of double facial palsy. Hughlings Jackson,* 
Dumenil,^ Charcot,^ and Joffroy, and lately Dow^se,' have contributed 
to the literature of the subject. 

Definition. — The condition under discussion may be described as a 
disease characterized by gradual loss of functions of parts supplied by 
the nerves taking their origin from the medulla, though the fifth nerve 
is rarely affected. 

It may be the result of morbid changes which are limited to the floor 
of the fourth ventricle; or, this region may be the chance site of 
sclerosis, which affects other parts as well. Such may be the lesion, 
whether " pseudo-bulbar paralysis " (the result of arterial occlusion) 
sclerosis, or glosso-labio-laryngeal paralysis exists ; the special symptoms 
are alike, and they appear one after another as the different nerves are 
involved. 



1 Op. cit., 2me edit. 

2 Lectures on Clinical Medicine, trans., vol. i. p. 908. 

3 Quoted by Trousseau, vol. i. p. 909. 

* Philosophical Transactions, part i., 1868. 
^ Gaz. Hebdoraadaire, June, 1859, p. 390. 

6 Archives, de Physiol., etc., torn, iii., 1870, p. 247. 

7 Brit. Med. Journ. Nov. 4 and 11, 1876. 



BULBAR PAEALYSIS. 415 

Symptoms. — The earliest expression of the disease is a certain loss 
of power of the lips ; the lower lip especially. If the individual attempts 
to whistle, his efforts may be unsuccessful, and the lower lip hangs so that 
the mucous surface is largely exposed. The tongue next follows, and its 
protrusion by the patient is a matter of difficulty. The individual is un- 
able to bring the tip in contact with the roof of the mouth, and incompe- 
tent to use it in the formation of certain consonants (the linguals). When 
he tries to speak or read aloud he finds great difficulty in pronouncing 
words containing the letters 1, n, c, d, g, h, j, t, w ; and in one of Trous- 
seau's cases the patient could not utter any letter but a. 

He may remain in this condition for some time — say for a year or two, 
when the tongue and lips become more extensively affected ; and not only 
are acts of a yoluntary character impossible, but the automatic movements 
of the tongue are almost totally embarrassed. The use of this organ 
in the management of food during mastication and deglutition is much 
impaired, and particles of food becoms lodged between the teeth and the 
gums and cheek. 

The patient's mouth is generally open, so that his teeth are exposed 
and from either side trickles a glairy stream of saliva. Next he cannot 
articulate the labials, and consequently his speech becomes worse than ever. 
He wears an inane expression, and is apt to attract the atten- 
tion of people in the street by his open mouth and silly appearance. 
The condition of the tongue has been noted by Dowse; its papillae bec:)me 
atrophied, and the surface very smooth. I have noticed that there is no 
loss of the sense of taste at any time. 

The palate next becomes the seat of the paralysis, and the pharyngeal 
muscles are so weak that deglutition is at first difficult, and finally 
impossible. Fluids are especially troublesome to swallow, and are 
apt to be regurgitated through the nares, and the voice becomes nasal 
and metallic as the upper part of the yocal apparatus becomes involved. 
The facial expression, always a marked feature of the disease, is now 
very pitiable. The tongue lies in the bottom of the mouth utterly devoid 
of power, so that the patient cannot protrude it, and it becomes useless for 
all purposes. If the posterior wall of the pharynx be irritated, there is 
none of the reflex response which is so marked in the normal state, but 
only pain is produced. Such was the condition of affairs noticed in one of 
Dr. Dowse's patients. 

The epiglottis does not cover the larynx ; and there is a tendency to 
choking from the accidental introduction of food, so that eating becomes 
a dangerous undertaking. The voice grows very weak, and the sufferer 
can no longer even make the almost unintelligible sounds which charac- 
terized the early stages of his disease. 

His' breathing now becomes very irregular, the inspirations are quite 
slow and shallow, and he sinks from sheer exhaustion due to insufficient 
nourishment and becomes a mere wreck, dragging himself about, and look- 
ing forward to death as something which alone is to bring relief. As the 



416 BULBAR DISEASES. 

neumogastric becomes more and more involved, the respiration undergoes 
changes which result in asphyxia. 

For some time before the end, his sufferings grow intense. Mucus 
collects in the bronchi, which he is unable to remove by coughing, and 
he sits in his chair with a feeling of greater security than when lying 
down, for in the supine position the saliva finds its way into the 
larynx, and produces suffocation. Loss of consciousness or mental impair- 
ment is never a symptom of the disease unless it be of the complicated form. 

The following interesting case was reported recently by Dr. A. H. 
Smith,^ of this city: — 

The subject was a clergyman, aged sixty-one years. About fifteen years 
ago, after prolonged and severe exercise of the voice in preaching, he be- 
came hoarse, and ultimately his voice failed so that he could speak only 
in a whisper. 

After the lapse of a year he gradually regained the use of the larynx, 
but as he did so he became sensible of an imperfection in his enunciation 
of certain syllables, especially those containing the letters p, t, d, s, etc. 
This difficulty has increased until now the power of uttering the labial and 
lingual sounds is almost entirely lost. 

Later a difficulty in swallowing was gradually developed, which has 
reached such a degree that only ^uarm fluids can be taken, and these with 
great care and hesitation, as they are apt to cause strangling, and to return 
through the nose. Mucus accumulates in the fauces, which he has 
great difficulty in getting rid of, and which causes a sense of strangu- 
lation. 

He finds that the movements of the tongue are very much restricted, and 
he has not the full control of his lips. 

His sight, taste, and smell are as perfect as is usual in persons of his 
age. The sense of touch, even in the paralyzed parts, is not impaired. 

He feels much less distress when the weather is warm, and dreads the 
approach of each winter. 

Such is the account which the patient — a very intelligent man — gave 
of himself As to the objective appearances, the patient moved slowly 
and feebly, but this was evidently the result of mere debility. The next 
notable thing at a cursory glance was the expression of his mouth. The 
orbicularis muscle was entirely paralyzed, permitting the lower lip to fall 
away from the upper, and to become partly everted. There was also 
relaxation and eversion of theupper lip from the same cause. The leva- 
tores menti and the depressores ang. oris were not involved in the pa- 
ralysis, and by their aid the patient was able to bring the lips into contact ; 
but when so approximated they projected forward, leaving a space be- 
tween them and the teeth, and giving a very peculiar expression to the 
face. 

When the mouth was opened the movements of the tongue were ob- 
served to be very slow and very much restricted. The tip could not 
be turned upward to touch the roof of the mouth, nor backward beyond 
the bicuspid teeth. The tongue was not notably changed in shape or size. 

All the muscles of the soft palate, including the palato-pharyngi 
and palato-glossi, were paralyzed, so that when the head was thrown 

1 Med. Record, Nof. 24, 1877. 



BULBAR PARALYSIS. 417 

backward the relaxed velum fell of its own weight against the posterior 
wall of the pharynx. The finger carried into the fauces produced scarcely 
any local reflex action, showing that the constrictors were complicated ; 
but sensation was perfect, and the reflex action of the stomach seemed 
unimpaired, efforts at vomiting being readily excited. 

There was a very profuse secretion of mucus fr( m the larynx and 
pharynx, which was gotten rid of with the utmost difficulty. There being- 
perfect inability to contract the cavity of the pharynx, the air which was 
forced from the larynx in the act of hawking escaped into a great loose 
bag, instead of into a narrow, firm passage, and thus it failed to drive the 
mucus before it. The paralysis of the soft palate added to the difficulty, 
for when by great labor a portion of mucus was coughed up into the back 
part of the mouth, the non-closure of the isthmus faucium permitted it to 
fall back again upon the larynx. 

Examination with the mirror showed that the laryngeal muscles re- 
tained their activity, and the cords, with the exception of slight hyperse- 
mia, were normal. The respiratory muscles were as yet unimpaired. 

In this case it is not probable that the loss of voice, which occurred in 
the early stage of the disease, was owing to a central lesion, since, after a 
year had passed, the larynx gradually regained its power. Moreover, 
laryngeal paralysis of bulbar origin does not usually occur in this asso- 
ciation until after the paralysis of the lips, tongue, and soft palate has 
become well-marked. It is more than probable that the aphonia was the 
result of a catarrhal affection, and that if life continues long enough, 
there will be a return, but this time from advancing change in the me- 
dulla. 

The greater ease in swallowing warm fluids is characteristic of dyspha- 
gia from almost any cause. Thus it is observed in both organic and 
spasmodic stricture of the oesophagus, and also when dysphagia results 
from the pressure of a tumor. 

Dowse ^ considers the disease to be either progressive, stationary, or re- 
trogressive, and if it were not for the single case of the last variety, which 
he publishes, I should not be prepared to accept the two latter divisions 
This he calls reflex bulbar paralysis. His patient, a woman aged 59, suf- 
fered from Bright's disease and inflammation of the maxillary and parotid 
glands. After her recovery from the last-mentioned condition, there was 
paralysis of the hypoglossal, facial, and spinal accessory nerves, as well 
as the third division of the fifth. The vocal cords acted feebly, and she 
could scarce speak in a whisper, being able to pronounce only the lin- 
guals r and s, and could not protrude her tongue ; food lodged in the 
cheeks ; saliva dribbled from the mouth ; she was unable to blow out a 
candle, while deglutition was interfered with to some extent. Strange to 
say, there has been improvement. It Avould be well, however, if Dr. 
Dowse had allowed a longer time to elapse before coming to a conclusion 
in regard to the retrogressive character of the disease in this instance, for 
the parotitis may have been simply a coincidence. I am inclined to think 
that the history of any genuine case thus far reported has shown a ten- 
dency to progressive decline, which, though delayed in some instances, 
has nevertheless steadily advanced to a fatal termination. 

^ Brit. Med. Journ., Nov. 11, 1876, p. 615. 
27 



418 BULBAR DISEASES. 

Causes. — The disease is one of middle age, and attacks men more 
often than women. It is usually the result of syphilis, and sometimes 
follows exposure and mental worry. Dowse considers the causes of the 
peripheral symptoms to be the following : — ' 

Dived. 

1. Progressive interstitial neuritis. 

2. Thrombosis. 

3. Hemorrhage. ^ 

4. Morbid growths. VKare. 

5. Vascular spasm, j 

Indirect. 

1. Reflex action from peripheral irritation. 

2. Inhibition from shock to central cerebral ganglia. 

Morbid Anatomy and Pathology. — Trousseau's autopsies re- 
vealed induration of the medulla, atrophy of the roots of the hypoglossal 
and spinal accessory nerves, thickening, and gray discoloration of the 
dura mater on a level with the medulla, which extended as far down as 
the roots of the fourth cervical pair. " This thickening was due to a 
considerable increase in the amount of fibers of connective and fibro-elastic 
tissue, and seemed to result from a chronic congestive process, as shown 
by the great number of capillaries and of deposits of hsematin external 
to them. The motor nerve-roots of many cervical nerves were found 
thinner than they should be from disappearance of nerve-tubes. The fifth 
and glosso-pharyngeal nerve-roots were healthy, and the muscular tissue 
of the paralyzed parts was found to be normal." 

Dumenil published a case which was probably progressive atrophy ; 
but some of the symptoms were those of the disease under consideration. 
In this case there was extensive atrophy of the roots of the hypoglossal, 
pneumogastric, and facial nerves, as well as a great many other changes. 

Fox^ considers an absolute or partial disappearance of the nerve-tubes, 
with preservation of the neurilemma at the nerve-roots, to be a constant 
lesion; and Wilks^ found that the roots of the hypoglossal and spinal 
accessory nerves had undergone atrophy, and become reduced to " little 
thin gelatinous threads." 

Sclerosis may occasionally involve the medulla, and produce symptoms 
characteristic of loss of function in the nerves to which I have alluded. 

Charcot^ gives, among other cases, one that involved the medulla ex- 
tensively. A patient of his presented, besides the ordinary symptoms of 
disseminated sclerosis, three months afterward, evidences of invasion of 
the pneumogastric and hypoglossal nerve-roots. There were dyspnoea 
and dysphagia. The patient was obliged to eat more slowly ; and often- 
times the food was regurgitated through the nostrils. Death followed in 
about six weeks afterwards, and was preceded by asphyxia. 

^ Op. cit., p. 234. 2 Guy's Hosp. Eep., vol. xv. 

^ Lepons sur les maladies du systeme nerveux, Paris, 1872-73. Premiere partie, 
p. 234. 



BULBAR PARALYSIS. 4l9 

The autopsy revealed the following state of the nervous centres : A 
section made one centimetre below the protuberance, at the point of origin 
of the trigeminus, disclosed a point of sclerosis. Other transverse sec- 
tions were made at the smaller part of the olivary bodies, and a sclerosed 
patch was discovered. Another patch was seen at the root of the pneu- 
mogastric. Examination by the microscope revealed a number of broken 
nerve-tubes and broken-down cells at the nuclei of the hypoglossal, and 
traces of irritation in the white substance of Schwann in the pneumogas- 
tric fibers. The pharynx and larynx were healthy. 

The observations of Lockhart Clarke have shown the intimate rela- 
tionship of the nuclei of the important cranial nerves which become af- 
fected in bulbar paralysis. There is a set of nerve- cells common to these 
nerves, and disease of the nuclei of one nerve is very likely to extend to 
others of the group, so that ultimately there is a general invasion, which 
is bilateral and never one-sided. 

The destructive process is probably myelitis, as Leyden has suggested, 
and disappearance of the motor-cells is the direct cause of the paralysis. 

It is a curious fact that the sixth nerve invariably escapes when we 
remember that it arises from a common nucleus with the seventh, as 
demonstrated by Lockhart Clarke and Stilling. In regard to the partial 
paralysis of the facial as an early symptom, and the subsequent increase 
in the area paralyzed, we must remember Romberg's statement that in 
organic brain-disease the entire distribution is not affected, but that the 
fibers involved are those that supply the muscles of the upper lip and alse 
of the nose; and this is an important point in the diagnosis from periphe- 
ral paralysis ; and Dowse calls to mind the fact that bilateral paralysis 
of the muscles supplied by the facial is connected with lesion at the root 
of the nerve. 

The aphonia may result, according to Dumenil, either from paralysis 
of the thoracic muscles, or those of the larynx. The ptyalism I am in- 
clined to ascribe, in the later stages, to paralysis of the chorda tympani, 
but agree with others who have observed it, that the accumulation of 
saliva in the first stage is due more to the patient's inability to swallow 
it than to anything else. Respiratory troubles may be due to paralysis 
of the pneumogastric and its motor, the spinal accessory. 

Dowse has divided the disease into three stages as regards the diffi- 
culty of swallowing, the first of which is connected with paralysis of 
the hypo-glossal; the second with paralysis of the motor branches of 
the glosso-pharyngeal ; and the third with paralysis of the spinal acces- 
sory. 

Voisin, in speaking of the alterations in speech, defines them into stut- 
tering, drawling, hesitation, jabbering, stammering, and quavering. The 
first three are due to lesions of the nerve-tracts which pass from the an- 
terior cortex to the medulla oblongata, and which traverse the corpora 
striata, crura cerebri, and pons, and are connected with disturbances of 
will. The other three have no such origin, but depend upon inco-ordina- 
tion of the muscles supplied by the hypoglossal, facial, and glosso-pharyn- 
geal nerves. 



420 BULBAR DISEASES. 

Diagnosis. — Facial palsy, general paresis of the insane, progressive 
muscular atrophy and diphtheritic paralysis may suggest themselves, and 
some are rather difficult to exclude, among them tumor, which however 
is often attended by convulsive attacks : — 

1. Facial palsy may be suggested, but as this disease is of sudden origin, 
and affects other muscles than those about the mouth, there need be no 
reason to confound it with bulbar paralysis. 

2. The early symptoms of general paresis of the insane somewhat 
resemble the initial symptoms of the disease of which we are speaking. 
There is tremor of the tongue, however, in addition to the embarrass- 
ment of speech ; contracted pupils and subsequent psychical symptoms 
make the diagnosis clear. 

3. Progressive muscular atrophy, rarely attacks the tongue primarily, 
and only one case has been reported (by Charcot) where there were any 
bulbar symptoms. The subsequent atrophy of other muscles will dispel 
any doubts the observer may have. The affection of the medulla is ordi- 
narily a final result of the extension of the central disease in progressive 
muscular ati*ophy. 

4. Diphtheritic paralysis is symptomatized by initial paresis of the 
muscles of the pharynx, and the tongue is seldom involved. A previous 
history of diphtheria will confirm the cause of the paralysis, should there 
be a suspicion. 

Prognosis. — As I have said. Dowse believes that there are forms of 
the disease which may be cured, viz., the stationary and the retrogressive. 
I cannot believe that when once affected by inflammatory disease, such 
extensive alteration, and such decided symptoms as he mentions, can ever 
be removed. 

The histories of the cases reported by the several observers already 
mentioned certainly offer a gloomy prospect and little encouragement for 
the victim. The only case reported as actually cured was that of 
Cheadle,^ and from the pain, visual trouble, and unilateral paralysis, it is 
improbable that the case was one of genuine bulbar paralysis. 

Raynard^ reports a case of bulbar paralysis with violent heart dilata- 
tion, syncope and speedy death. The heart was found after death to be 
greatly increased in size, and though its valves were unaffected, there was 
very decided dilatation of all the cavities. 

Treatment. — Nothing has been done which has resulted in any de- 
cided improvement. I am sorry to say that electricity did no good in 
the one case I have treated, but Duchenue^ in several cases found that 
systematic faradisation greatly facilitated articulation and otherwise 
helped his cases. Erb and Benedikt were particularly successful. Dowse 
recommends cod-liver oil, iron, and phosphorus, but Erb does not believe 
in the latter. 

1 Labio-glosso laryngeal Paralysis, St. George's Hosp. Eeports, vol. v., 1871, p. 123. 

2 Quoted by Pitres in his Thesis, 1878. 

3 De r electrisation, etc., 2d Ed. p. 649. 



CEREBRO-SPINAL MENINGITIS. 421 



CHAPTER XIY. 

CEREBRO-SPIXAL DISEASES. 
CEREBRO-SPINAL MENINGITIS. 

Synonyms. — Spotted fever ; Meningite foudroyante ; Head pleu- 
risy ; Myelitis petecliialis ; Cerebral or Cerebro-spinal typhus ; Menin- 
gite cerebro-spinale ; Fievre cerebro-spinale, etc. 

Definition. — A disease characterized by inflammation of the men- 
inges of the brain and cord, symptomatized by pain, tetanic spasms, and 
herpetic eruptions, and occurring in an epidemic form. 

This most terrible disease has of late years received a great deal of at- 
tention at the hands of German and French writers. Niemeyer^ was one 
of the first of the former to direct attention to the disease ; while in 
France, Broussais and others wrote extensively. There is no doubt as 
to the antiquity of the disease, for among the writings of Hippocrates a 
nearly perfect description of the malady is to be found. In our own 
country the epidemic character of the affection was noted by several of 
the older authors, among them North" (1811), Gallup^ (1815), and 
Minor* (1823), and their contemporaries. Outbreaks occurred at Med- 
field, Mass., Litchfield Co., Conn., and at various points in the Eastern 
and Middle States during the early part of the present century. Clymer,^ 
Jones,^ and others have since written exhaustively on the subject. 

Cerebro-spinal meningitis is certainly an irregular disease ; it is not 
contagious, and is influenced seemingly in no way by climate. 

Symptoms. — The appearance of symptoms is usually quite sudden, 
and their course is remarkably rapid and ordinarily tends to a fatal termi- 
nation. In exceptional cases pain in the back, headache, vomiting, or 
malaise may constitute a premonitory stage, which lasts a few hours ; but 
usually there is no such delay. A severe rigor, an attack of vomiting 
which is followed by headache of an intense description, and an elevation 
in pulse and temperature mark the commencement of the trouble. The 
child may present these symptoms, and in addition another which is 
invariably pathognomonic. 

^ Treatise referred to in Niemeyer's Text-Book of Prac. Med., vol. ii., p. 218. 

2 Treatise on a Malignant Epidemic, etc., 1811. 

^ Sketches of Epidemical Diseases, etc., 1815. 

* Essays on Fevers and other Medical Subjects, Middleton, Conn., 1828. 

° Aitken's Science and Pract. of Medicine, pp. 492-505, 3d Amer. edit. 

^ Med. and Surg. Memoirs, pp. 412-507. 



422 



CEREBEO-SPINAL DISEASES 



The head is drawn backivards and downivards, and the muscles at the 
hack of the neck are rigidly contracted. When the head is forced forward, 
or when the child bends forward to drink, the pain is greatly aggravated. 
At the same time the pupils are contracted. The child moans constantly, 
and is restless ; this is an early symptom, and may appear at the end of 
twenty-four hours, and be the first to attract our attention. 

Fis. 59. 




(J. Lewis Smith.) 

The pulse is now quite rapid, and may beat 100 to 120 per minute. 
The pain meanwhile increases, and affects the head as well as the entire 
length of the spine, and is increased by pressure. Just as in other forms 
of meningitis, the movements made by the patient aggravate his suffer- 
ing, and he usually strives to keep quiet. He is conscious for the first 
two or three days should he live so long, but at the end of this time he 
loses his intelligence after first growing delirious. The pulse, tempera- 
ture, and respiration are increased. The former sometimes beats 130 per 
minute, while the thermometer may indicate an advance of 104°, but it 
usually remains at about 100°. At an early period crops of herpes ap- 
pear upon the face and limbs, and the skin is hypersesthetic, and the 
patient cannot bear handling. After the first ninety-six hours the con- 
vulsions succeed the primary rigidity. Opisthotonos or other tetanic con- 
tractions make their appearance. Stupor follows, and he dies in a condi- 
tion of coma ; and according to Niemeyer death takes place with symptoms 
of oedema of the lungs. The bowels are constipated during the entire 
disease, and during the later stages the patient has involuntary discharges 
of urine. 

The above description is of an ordinary case. There are great varia- 
tions, and either death may take place in a fcAV hours, or there may be a 
tardy convalescence accompanied by structural changes of a very serious 
nature. The course of the disease may open with chill followed by rapid 
convulsions and coma, when the patient may die in less than twenty-four 
hours. 

In other cases, after the subsidence of the acute symptoms, which may 
last for a week or two, convalescence takes place, attended by headache 



CEREBEO-SPIXAL MEXr>'GITIS. 423 

and muscular contractions, which continue for some time. Deafness very 
often results ; and I have several times met with total loss of vision, and 
paralysis of some of the facial muscles. In one case brought to me from 
the interior of the State, there was rigid contraction of the muscles at the 
back of the neck ; and in another, seen with Dr. F. H. Rankin, now of 
Newport, besides ptosis, and paralysis of the pharynx, thei'e was an otor- 
rhcea with extensive middle-ear disease. This patient was quite an im- 
becile, intellectual impairment having begun after the subsidence of the 
acute stages. One of these chronic cases has been under observation 
for several years, but I have been unable to effect more than trifling 
improvement. 

Causes. — Epidemic cerebro-spinal meningitis seems to be much more 
common during cold weather, and is much oftener met with during infancy 
than at any other period of life. Adults are not exempt ; but the disease 
prefers the young. It is a disease, like typhus, which usually attacks 
the poor ; and bad ventilation and insufficient food seem to prepare the 
way for epidemics. In the city of New York the first outbreak of the 
disease appeared in 1866 ; and subsided, to reappear, February, 1872. 
In the sparsely settled wards of the city (the 19th, 20th, 22d), where 
building was going on and fresh earth turned up, it seemed to prevail. 
There were 45 fatal cases during the winter quarter in these wards, while 
the entire number of deaths in New York during the same period from 
this cause was 108. During the spring quarter there were 492 deaths, 148 
being in these wards. It subsided in the spring of 1873, but reappeared 
during the autumn of that year. It would seem, from these statistics, that 
overcrowding had but little to do with the disease, but that bad drainage 
(this portion of the city being imperfectly drained) had undoubtedly some 
influence. 

Morbid Anatomy. — The meninges of the brain show evidences of 
intense hypertemia, the sinuses being distended with blood which slowly 
coagulates, and the dura mater is the seat of ecchymotic spots. There is 
usually a sero-purulent exudation beneath the arachnoid, and this is found 
at the base of the brain as well as in the ventricles. It may be recognized, 
also, in the different fissures and sulci. The spinal meninges are the seat 
of the same exudation, it being found beneath the dura, or between the 
arachnoid and the pia mater. All of the spinal membranes are vascular, 
and opaque in spots. The exudation appears to be confined to the poste- 
rior parts of the cord ; and usually, when infiltration in the cord has taken 
place, small elevations may be observed beneath the pia mater. Accord- 
ing to the German pathologists, the cervical portion of the pia mater is 
not commonly the seat of exudation. The membranes are often adherent, 
and patches of false membrane are visible, so that sometimes the sub-cere- 
bral nerve-trunks are bound together and connected by bridges of organ- 
ized lymph. The nervous tissue proper is extensively softened in rare cases- 
especially if the inflammatory action has been at all severe. Spots of 
localized softening are, however, not uncommonly observed. 

Diagnosis. — Cerebro-spinal meningitis sometimes resembles certain 



424 CEREBEO-SPINAL DISEASES. 

irregular forms of malignant malarial fever, on account of intermissions 
in the febrile state. This is the case more especially during convalescence, 
when the affection assumes a periodical character. The chill in cerebro- 
spinal meningitis is not so marked as in the true malarial affection, and 
contractions of the muscles are rare in any form of malarial trouble. The 
other points ©f difference may be thus summed up : — 

CEEEBRO-SPINAL MENINGITIS. CONGESTIVE PERNICIOUS MALARIAL 

■D 1 r . J FEVER. 

Bowels constipated. I^ot usually so. 

Pulse and temperature do not suffer Both subject to great variations, feeble 

rapid variations. and irregular (Jones). 

Temperature does not undergo periodi- Temperature undergoes decided peri- 

cal changes. ^^^^^i changes. 

Face flushed ; eruption. Complexion sallow. 

Delirium and coma not affected by large ^n symptoms modified usually by nega- 

doses of quinine. ^ ^ ^i^,^ treatment with quinine. 

Increase of fibrin, and] rapid coagula- 
tion of blood when drawn. 

A malignant typhus, or a masked variola, might counterfeit cerebro- 
spinal meningitis ; or, on the other hand, acro-narcotic poisoning might 
simulate the affection. The presence of tetanic spasms of the post-cervical 
muscles is, however, so prominent a symptom that when it is absent the 
improbability of cerebro-spinal meningitis is considerable. 

Prognosis. — This disease, like other forms of meningitis, has a bad 
character. Death is generally the rule, recovery the exception. In the 
city of New York the total number of deaths from all causes was 29,084 
during the twelve months ending Dec. 31, 1873. Of these, 9593 were 
placed under the head of zymotic diseases ; and the number of deaths due 
to cerebro-spinal meningitis was 290. Of these, 69 were under one year, 
and 164 under five years. Very few cases were over thirty. In the ma- 
jority of cases the disease runs its course in from 4 to 20 days. In fatal 
cases death occurs generally before the 12th day. 

Treatment. — In regard to treatment, little can be said that will be 
encouraging. The ordinary antiphlogistic treatment, consisting of ab- 
straction of the blood by leeches applied to the mastoid processes, and blad- 
ders of ice to the head, and large do>es of calomel, according to some ob- 
servers, have cut short the disease, especially when these remedies were 
used at its commencement. The almost wonderful results that have fol- 
lowed the use of ergot in large doses suggest this remedy to us, and I 
have no doubt that it will prove to be very efficacious. Ziemssen recom- 
mends morphine, and has never observed any unpleasant effects following 
its employment, 

CEREBRO-SPINAL SCLEROSIS. 

Synonyms. — Sclerose en plaques dissemin^es (Charcot and Bourne- 
ville) ; Insular sclerosis (Moxon). 

Definition. — A disease of the human system, the essential lesions of 
which are patches of neuralgic degeneration irregularly scattered through 



CEREBRO-SPINAL SCLEROSIS. 425 

the* nervous substances of the brain and spinal cord, and involving chiefly 
the motor tracts. 

For a long time this disease was mistaken for paralysis agitans (Park- 
inson's disease), chorea, and other neuroses; and even after it had been 
shown to be a separate neurosis a certain amount of confusion existed in 
regard to its nomenclature and its position among the scleroses. Charcot 
and Moxon^ were the first to give it a distinct character. 

Symptoms. — We may divide the progress of the disease into three 
stages. 

1st Stage. — The first symptom, which is common to several other neu- 
roses, is gradual loss of power in the lower limbs, which, by itself, does 
not attract attention to the grave nature of the disease in its incipiency. 
With the weakness there is no atrophy and no loss of sensation, while 
reflex excitability is either normal or only slightly increased. The rec- 
tum is not afl^ected, nor is the bladder, and there is simply a paresis which 
lasts for a variable time, perhaps for two or three months, or for a much 
longer period. The partially paralyzed limbs become agitated by tremors, 
which are seen best when the patient takes some constrained position, or 
attempts to \valk a straight line. He may have the gait of an ataxic, but 
generally the walk is more like that of a general paralytic, being charac- 
terized by weakness of the extremities. As the disease invades a higher 
portion of the cord, we will find tremor of the upper limbs and paralysis 
of the cranial nerves, indicated by symptoms I shall describe in speaking 
of the descending variety. I may allude, however, to a particular defect 
in articulation, the patient being unable to pronounce some of the labial 
consonants. 

2d Stage. — Rigidity of the limbs supervenes, with various contractures 
of a spasmodic character, and exaggeration of the tremor. One of my 
patients died in her bed with her knees drawn up to her chin, her legs 
flexed on the thighs, and her arms drawn closely to her chest. It re- 
quired quite violent exertion for me to extend the limbs, and the tremor 
was markedly aggravated when I did so. Electro-muscular irritability is 
next greatly increased, and reflex excitability heightened. Epileptiform 
attack may now appear, as well as apoplectiform, and death may occur 
at this period from the invasion of some cerebral vessel and consequent 
cerebral hemorrhage. 

3d Stage. — This stage is marked by rapid decline of the patient's 
strength. Incontinence of urine and feces, bedsores, and dementia follow, 
and^ after other evidences of gradual wasting away, death may end the 
scene. 

The course of this form is : First, paresis of lower extremities and 
tremor ; second, contraction, and aggravation of tremor ; third, general 
dissolution. 

1st Stage of Descending Form : This is the condition of afiairs when 

^ Eight cases of insular sclerosis of the brain and spinal cord, by W. Moxon, M. D., 
Guy's Hospital Eeports, vol. xx., 1875. 



426 CEREBRO-SPINAL DISEASES. 

the cord is attacked secondarily. When the disease begins in the bra'in, 
the early symptoms may be headache, convulsions, vertigo, or, what is 
more common, paralysis of some of the cranial nerves ; there may be 
ptosis, strabismus, loss of hearing, and facial paralysis, or troubles of 
speech and embarrassment in swallowing. The important symptom next 
in advance is the appearance of tremor, which is first seen in the tongue, 
which, when protruded, trembles visibly ; or it may affect the lips, as may 
be noticed when the patient speaks. The eyeballs oscillate (nystagmus), 
and the head may become agitated, and afterwards the upper extremities. 
A peculiarity characteristic of all forms of sclerosis is not absent here, 
viz., the aggravation of tremor by voluntary efforts made to control it, 
and its diminution during rest. If the individual attempts any complex 
action, he is utterly unable to complete it properly, for the movements 
increase until muscular control is entirely lost. I have alluded to the lost 
sense of location, which is also seen in advanced locomotor ataxia, and I 
may state that it is also a symptom of this form of sclerosis. 

2d Stage : The limbs lose their power to a great extent as the disease 
advances, and permanent contractures of the upper and lower limbs, 
which by this time are affected, render the patient very uncomfortable. 
His forearms may be flexed, and the fingers are doubled up, as is the case 
in uncomplicated lateral sclerosis. The thighs are even flexed on the 
pelvis, and the legs may be as well. The knees are approximated quite 
forcibly, and it is often difficult to separate them. This stage may last for 
several years. 

3d Stage : Meanwhile the tremor has continued, and increased in vio- 
lence ; but it may sometimes be stopped by flexing the great toe, just as 
Brown-Sequard has shown may be done in epilepsy. The bladder and 
rectum are now involved, and the patient suffers terribly from cystitis, 
and is prostrated by diarrhoea. Bedsores form, and he gradually sinks 
into a state which invariably has a fatal termination. In both varieties 
there is great diiflculty in articulation, and disturbance of function in 
those organs supplied by the lower cranial nerves. The lower lip falls, 
and there is dribbling of saliva, while food often remains in the mouth 
wedged between the teeth and between the gums and cheek, and liquids 
find their way through the nostrils. Beyond slight irritability and rest- 
lessness, there are usually no mental symptoms at the outset, or until the 
fixed stage, when sometimes there is intellectual as well as physical de- 
cay ; but this is not the rule. A case which seems to be of great interest, 
because of the atrophy of the upper limbs, came under my notice two 
years ago, 

E. "W., aged 37, salesman, no family history of nervous trouble. Father 
and mother alive ; nothing to account for his present condition. Five 
years ago he was employed in a dry goods store, and his attention was 
called to a slight weakness in his thumb and forefinger of the right hand 
when he used his scissors. There was subsequent tremor, which annoyed 
him excessively, and which subsequently became quite general. About 
the same time he was subject to very severe headache, vertigo, and some- 



GEREBRO-SPINAL SCLEROSIS. 427 

times vomitiDg. The tremor meanTvliile increased, ?nd ifc became so vio- 
lent when he attempted to execute some fatiguing act that he was forced 
to desist. He next noticed that his vision was beginning to be impaired, 
that be saw double, or that " mist floated before his eyes." The tremb- 
ling continued, and when he came to me I found his condition to be as 
follows : The patient is a tall man, of decidedly nervous temperament, 
quite feeble and emaciated, and very much depressed. Both arms are 
convulsed by tremors, but especially the right. The biceps and the ex- 
tensors of the hand are much atrophied, and there is great loss of power. 
He tells me that the tremor has been much more violent than it is now. 
The sensibility of the cutaneous surface is rather lowered, and there is a 
certain amount of analgesia, so that pins may be run into the dorsal 
aspect of the forearm without producing pain. He was able to press the 
fluid in the dynamometer up to 7.50 with the right, and to 17 with the 
left. There is still headache at times, and some dizziness. The left eye- 
lid seems to cover the eyeball more fully than the right, and the muscles 
of the left side of the face were trembling quite violently. When I told 
him to whistle, his lips trembled so much that he could not do so ; and 
when I requested him to repeat the line " Ben Battle was a solider bold," 

('tutter) (hesitation) (slow) (explosion) (explosion)* 

he did it as follows : " Me-e-n m-m-m-etta was a s o o g a m-mold." His 
articulation was quite defective, and I had great difficulty in understand- 
ing him. His tongue trembled, and his lower lip seemed to sag and fall 
forwards, and he was obliged to wipe his mouth quite constantly, as there 
was a considerable escape of saliva. \Yhen I told him to hold his head 
in such a position that I might examine his eye with the ophthalmoscope, 
it shook to a great degree, and I had difficulty in illuminating the retina. 
He says this is recent, and that his head was not affected by tremor until 
a month or two ago. His mind is clear, and his memory unimpaired. 
I have seen him but once, and there has been no advance in his condi- 
tion. 

The following case is reported by Bourneville : — ^ 

Rosine Spitale, 20 years old. At 17 years of age she was suddenly 
affected (after crossing a small stream and becoming chilled) with loss of 
power, first in the right lower extremity, and then in the left, and some 
time after the hands began to tremble. At 18 there was some subsequent 
improvement, but it was very slight. Soon afterwards menstruation 
ceased, and some time after this the symptoms reappeared. Hemiplegia 
occurred without loss of consciousness or convulsions, and the tongue and 
eyes were involved. The disturbances of sensation were moderate ; there 
was a certain amount of numbness in the lower limbs, and a sense of clum- 
siness of the tongue, with difficulty in articulation, and some diminution 
of mental power. At the beginning of 1853 the patient was well nourished. 
A -half grain of strychnine daily has produced an amendment for ten or 
twelve days. Electrization produced movements in the lower limbs, and 
increased the trembling in the upper extremities. In the course of the 
month the paresis of the inferior extremities was nearly complete, the 
trembling of the eyes with dilatation of the pupils is quite pronounced, 
and the patient has become very stupid. 

* The intonation was very much like what we would expect to find in " cleft 
palate," 

^ La Sclerose, etc., Paris, 1869, p. 92. 



428 CEEEBEO SPINAL DISEASES. 

January, 1854. The hands tremble less than they did. There are in- 
voluntary discharges of urine. Ergot Jij per day has been used for 
several months. It acted once upon the sphincters, and seemed to improve 
the weakness of the limbs, for several movements were possible. 

Spring, 1854. Bedsore on sacrum. 

September. In a state of decline; the bedsore has extended very rap- 
idly; pain in the head ; pulse 136. 

October. Repeated rigors ; sensibility of the inferior limbs returned ; 
feebleness of the extensors of the back ; scoliosis toward the right ; the 
trembling in the extremities persists. 

November 1. Death, preceded by involvement of the muscles of the 
pharynx. 

Autopsy. — The gray matter is hard ; the nervous substance in the 
neighborhood of the lateral ventricles and that of the protuberance were 
hard. We found gray nodules superficial and deep. The white substance 
had become hard in spots. Beneath the microscope the indurated nodules 
(white) consisted of a fibrous, moss-like, connective tissue ; the elements 
of the nervous matter had almost entirely disappeared ; and the white 
nodules were pressed beneath the surface of the cut. The spinal cord 
was indurated. The great vessels and viscera were healthy. 

Dr. Geo. S. Gerhard^ has presented the following interesting case of 
this disease: — 

Samuel A., set. 57, a native of Ireland, and a blacksmith by trade, 
was admitted into the out-patient department of the Infirmary for Nervous 
Diseases on September 17, 1876, and gave the following history. His 
health had always been good until about seven years ago, when, after no 
known cause, he began to lose power in the legs. One year after this his 
arms grew weak, and he then observed for the first time that any move- 
ment of the upper or lower extremities was accompanied by tremor. At 
a somewhat later period his speech became affected. The weakness of 
his limbs and the trembling gradually increased, until finally, about four 
years ago, he was obliged to give up work. 

On admission there is decided loss of power in the upper and lower 
extremities, and upon his attempting to use either, a large and jerky tremor 
is developed. He walks with the assistance of a cane, but his movements 
are slow, and his feet clear the ground with much difiiculty. His grip; 
particularly that of the right hand, is feeble, squeezing the dynamometer 
with the former to 100° and with the latter to 110°. In the upper ex- 
tremities the trembling is especially well shown during the performance 
of an act requiring some little time for its execution, such as lifting a glass 
of water to the mouth. The tremor also involves the muscles of the head 
and trunk, but it ceases entirely when the patient is in a state of absolute 
repose. There is no muscular wasting, no loss of electrical response, and 
no disturbance of sensibility. 

His mental faculties are decidedly impaired, and his speech is thick 
and deliberate, there being a decided interval between each word. His 
eyesight is poor, and examination of the fundus reveals commencing 
atrophic changes, as shown by attenuation of the vessels and a general 
pallor of the optic disk ; there is also slight nystagmus. The unsteadiness 
of gait and the tremor are not increased by closure of the eyes. His urine 

^ Philadelphia Medical Times, November 11, 1876. 



CEREBR0-8PINAL SCLEROSIS. 429 

is in all respects normal, and he has no loss of control over the bladder 
or bowels. 

Causes. — Jaccoud is of the opinion that sclerosis occurs as a disease 
of childhood, or adult life up to 45 years, and that there is nothing to indi- 
cate the special liability of either sex ; whilst Charcot considers it a dis- 
ease which is much more common among females than males, and that it 
rarely appears after 40. Of six cases I have recorded their respective 
ages were 18, 26, 33, 37, 41, 46 ; four were males and two females. Of 
eighteen cases collected by Bourneville fifteen were women and three men. 
In three of these the disease began between 36 and 40, three between 30 
and 35, and the others between 15 and 30. Very little is known in re- 
gard to the etiology of sclerosis ; but " moist cold," emotional excitement, 
and venereal excesses are spoken of by the different Continental writers 
as causes. 

Bourneville found that the greater number of his cases died between 35 
and 50, and that the disease appeared in most instances between the ages 
of 26 and 35. In one of my patients the disease began at the 5th year, 
in another at about the 18th year, and in the third and fourth at 32, and 
in the fifth and sixth between 35 and 40. 

Morbid Anatomy and Pathology. — I have spoken in another 
chapter about the morbid appearances in sclerosis, and nothing remains to 
be said in regard to this particular form. It is only a question of loca- 
tion that concerns us, and after death we will probably find patches of 
tissue scattered through the brain and cord. ^ The antero-lateral columns 
seem to be invaded in nearly all cases, and this would appear probable 
from the contractures. 

Diagnosis. — In the ascending form it must be remembered that the 
tremor follows the paresis, while the descending form is characterized by 
tremor as a primary affection, or at least before the muscular paresis of 
the extremities. Paralysis agitans may be confounded with the descend- 
ing form of the advanced disease ; the tremor in the former disease is 
continuous, and is often not affected by quieting influence or sleep, but is 
not aggravated by efforts of the will. The early symptoms of this form 
may also point to progressive paralysis of the insane, and to intracranial 
tumors ; but the subsequent progress of the affection, the development of 
new symptoms, and the common absence of neuro-retinitis, are sufl^icieut 
to remove any doubts as to its true nature. 

Prognosis. — Invariably bad. 

Treatment. — I know of no remedy that can reconstruct a degenera- 
tion of nerve-tissue which consists in proliferation of connective-tissue 
cells, and nerve-tube disappearance. Nitrate of silver, tribasic phosphate 
of silver, chloride of gold, galvanism, bichloride of mercury, and chloride 
of barium have been all used. It seems that only one chance may exist 
— the possibility of syphilis. If this be present, it is probable that spe- 
cific treatment will be successful. We are to improve the patient's gene- 
ral condition, and relieve his tremor either by conium or hyoscyamia, and 
make him as comfortable as possible. 



430 CEREBRO-SPINAL DISEASES. 

ALCOHOLISM. 

ACUTE — CHRONIC. 

Synonyms. — Ebrietas, Alcoholismus, Delirium tremens ; Mania a 
potu, Alcoolisme; TriiDksacht ; Chronic alcoholic intoxication (Reynolds). 

Definition. — A disease of the nervous system resulting either through 
direct action of alcohol upon its tissues, or through impairment of other 
organs which fail to remove effete substances from the blood ; and symp- 
tomatized by mental aberration, and by various sensorial and motorial 
phenomena, usually the result of lowered functional activity. 

The immoderate use of alcoholic beverages is usually followed by the 
most deplorable consequences. Sad to say, this condition is too familiar 
to need any extended description, as far as the appearance of the patient 
is concerned ; but there are other features of the disease that need earnest 
and careful study. 

The effects of alcohol upon the human being may be said to be physio- 
logical and pathological. The sensorial alterations are much more inte- 
resting than the motorial, and of these we will speak in detail. 

The imbibition of a moderate amount of alcohol, as we know, is usually 
followed by a general feeling of comfort, a certain degree of exhilaration. 
The individual is no longer absorbed in himself. He is animated and 
gay, his ideas flow rapidly, and he becomes filled with greater energy and 
endurance. If the dose be increased, the mental functions become more 
active. He is excited and demonstrative, and either violent and noisy, 
or tender and maudlin, according to the thoughts which have most en- 
grossed his attention, or through the influence of temperament. Incohe- 
rence of speech and confusion of ideas succeed the ordinary mental ex- 
citement, and this may be followed by a condition of stupor, the individual 
becoming perfectly unconscious of injury, and unmindful of either bruises 
or cuts, or even severe burns. He may stagger and fall, and lie in some 
exposed place regardless of the blaze of the sun, the flies, and the noise. 
He has finally become reduced to what Magnan^ calls " la vie vegetative." 
He is " dead drunk." This deep alcoholic stupor may last for some time, 
and end the patient's career; or he may become maniacal instead, or 
present the condition described by Percy ^ under the name ivresse con- 
vulsive, in which, with clonic convulsions, he grows furiously maniacal, 
grinding his teeth, and cursing and menacing those about him. The 
maniacal attacks are no doubt influenced to some degree by the character 
of the illusions and hallucinations. 

ACUTE ALCOHOLISM. 

Symptoms.— The continued use of alcohol in excess for a week or 
two, such as occurs during an ordinary debauch, is very apt to lead to an 

^ Recherches sur les centres nerveux, p. 116. 

2 *' Art. Ivresse Convulsive," Dictionnaire des Sciences Medicales, t. xxvi., p. 249. 



ALCOHOLISM. 431 

attacli of delirium tremens. This state of acute alcoholism may also occur 
should the patient, who has drunk not necessarily to intoxication, but to 
a degree almost approaching it, be deprived of his drink. 

One of the earliest indications of this state of alcoholism is a tremu- 
lousness or " shakiness," which is quite marked in the early part of the 
day, and is connected with nausea and want of appetite. The patient is 
restless and irritable, sleeps poorly, and presents an appearance of dejec- 
tion and sadness. His eyes are red and watery, and his skin is of a 
muddy color. His features are drawn and haggard, and he is a wretched 
object indeed. The gastric irritability may be so great as to prevent any 
retention of food, and the simplest forms of nourishment are ejected by 
the stomach. Constipation is obstinate, and the urine is passed in small 
quantities and loaded with the urates, so that a dense brick-dust precipi- 
tate is found in the chamber. The attack is immediately preceded by 
great excitability, and by illusions and hallucinations, which grow very 
marked as the patient becomes noisy and violent. Magnan has graphi- 
cally described the different varieties of mental trouble. The patient 
may be sad and utterly dejected. He may imagine that he has committed 
some great crime ; that he has been sentenced to death ; that he is being 
executed; and these delusions may markedly influence the character of 
his outward expression. In nearly every case there is some delusion of 
persecution of a horrible kind. The attack usually begins with halluci- 
nations of a visual character, in which snakes and other reptiles, devils, 
imps, gnomes, and goblins terrify the patient. In one instance which I 
remember, he was tortured by devils who held lighted candles, and were 
about to set his clothes on fire ; in another case the patient endeavored 
to escape a falling weight. The illusions are always followed by halluci- 
nations, and finally by delusions. The irritations of the organs of sense 
are distorted so that the simplest and most common noises become changed 
by the patient's disordered imagination into the most terrible sounds. 
The cry of the vendor in the street is likened to the despairing shriek of 
a lost soul. The stroke of the clock, a funeral bell, and the voices of 
those in the room are supposed to be the savage yells of a howling mob. 
The objects which the patient sees are nearly always transformed into 
animals, which, controlled by no natural laws, run over the ceiling, or 
gallop through the air. Odors are reversed, and food is supposed to be 
poisoned. Animals run over the skin; sometimes they are rats or lizards; 
and at others he may call attention to the torture inflicted by thousands 
of needles or cutting instruments. Maniacal outbursts are the common 
feature of the attack, the patient seeming to possess herculean strength, 
and it is sometimes necessary to have six or eight strong men to prevent 
him from throwing himself out of the window, or committing some deed 
of violence. He may remain in this condition for several days at a time, 
during which period he neither sleeps nor eats. His eyes are bloodshot, 
and he sweats profusely. The pulse ^ is very rapid, small, and irritable, 

1 The sphygraograph has been employed by Anstie in cases of delirium tremens, 
and the tracing obtained very closely resembles that of the t^'phoid fevers and in- 
flammation. It is of a marked dicrotic type. 



432 CEEEBRO-SPINAL DISEASES. 

and thougli the deep temperature may reach 102° or 103° F., the hands 
and feet are cold, and the palms and soles clammy. 

When recovery takes place, the first change for the better is sleep. The 
violent symptoms subside gradually in the reverse order of their appear- 
ance. He may awake, after fifteen or eighteen hours, irritable, but not 
much better ; or there may be a lesser degree of excitement, more sleep, 
and gradual improvement. 

In other cases death follows, there being a subsidence of the violent de- 
lirium, which changes its character and becomes muttering; when he 
relapses into a typhoid state, and gradually passes away. 

The tendency to the commission of deeds of violence is quite charac- 
teristic of acute alcoholism. Of 377 cases observed by Bouchereau and 
Magnan^ in the year 1870, twenty- four attempted to commit suicide, and 
nine attempts at homicide were made. These cases were seen under re- 
straint, but among the cases which occur outside of hospitals and asylums, 
the number is far greater. 

Lancereaux has described the features of acute absinthism, which, 
however, is rare in this country. He agrees with Magnan, that epileptic 
attacks exactly like those of the ordinary disease follow the immoderate 
use of absinthe. Several hours after the toxic dose of this liquor has 
been taken, the convulsions take place, and involve chiefly the muscles 
of the back and of the posterior part of the neck, so that a species of 
opisthotonus results. These tonic convulsions are followed by others of 
a clonic character, affecting chiefly the muscles of the face. There is 
frothing at the mouth and grinding of the teeth. The muscles of the 
body are also next in a state of clonic contraction. The actual attack 
lasts for an hour, and is not followed by coma. It is separated by inter- 
vals of comparative quiescence. The patient then falls asleep, and, after 
a variable time, awakens comj)laining of sensory disturbances. 

In an abstract of Lancereaux's article by Decaisne,"^ an admirable de- 
scription of acute absinthism is given. He calls attention to the fact that 
the cry and coma are absent in absinthe epilepsy, and the attack is irre- 
gular, and resembles a convulsive attack of a hysterical character. 

CHRONIC ALCOHOLISM. 

Symptoms.- — A much more grave condition of affairs follows the 
continued use of large quantities of alcohol, and no more hopeless disease 
exists than that of which we are about to speak. While in delirium tre- 
mens recovery may take place, followed by total reformation, without any 
serious damage to the nervous system, the more serious nerve-changes 
wrought by constant saturation can never be repaired, but tend to further 
degeneration and decay. 

Chronic alcoholism begins by a number of insidious alterations in the 

^ Op. cit., p. 129. 

' Eevue des Sciences Med., No. 33, 1881, p. 231. 



ALCOHOLISM. 433 

nervous substance, whereby its functional activity is embarrassed, and 
minor symptoms at first, and more grave ones afterwards, appear very 
gradually and progressively. 

The victim of chronic alcoholism may present the symptoms of tremor 
and loss of power of which I have before spoken. The tremor is rhyth- 
mical, and begins at first in the extremities, and afterwards involves the 
entire body. There seems to be an accompanying want of power, for he 
relaxes his hold upon any object he may grasp when his attention is di- 
verted. His morning dram involves an effort worthy of a better cause. 
He grasps the glass- with both hands, feariug that he may spill even a 
single drop of the precious liquid, and carries it carefully to his mouth, 
clutching the rim of the glass between his teeth, oftentimes with sufficient 
force to bite out a piece. The lower extremities become involved, and 
the patient shuffles along in a clumsy manner, his feet being scarcely 
lifted from the ground. His dress becomes disorderly, and his habits are 
no longer characterized by neatness and tidiness. His facial muscles 
lose their play, and his countenance wears a wonderfully woebegone and 
sorrowful expression. He wanders wretchedly from one grog-shop to an- 
other ; eats sparingly, and rarely ever, unless his worn-out stomach is 
stimulated by a dram. He loses flesh, and his clothes hang to his with- 
ered limbs like the vestment of a scarecrow. This is but the first step in 
the advancing disease. Memory becomes weakened, and forgetting even 
faces and names, he drops one by one his old friends, and sits in loneliness 
for hours at a time. 

The mind is utterly sapped, and he is reduced to a state of dementia. 
Numerous grave changes occur in addition to these. Speech becomes thick 
and unintelligible. In the early stages there may be convulsions or attacks 
of delirium tremens ; but one of the most striking and serious expressions of 
the disease is the occurrence of paralysis; and there may be hemiplegia or 
paralysis of a local character, the third nerve becoming implicated, and 
ptosis resulting. The subject of chronic alcoholism is generally anaesthetic, 
and this to a marked degree. Not only is tactile sensibility impaired, so 
that he is unable to determine the nature of even a rough object, but he is 
unafiTected by extremes of temperature. In one case which I can recall, this 
was illustrated by the fact that in sitting before the fire he thrust his foot 
beneath the grate, and left it there for some time before his position was 
discovered by a member of the family. Hemi-anseithesia ^ is spoken of by 
some writers, but it is an extremely rare feature of the disease, and is pro- 
bably a late symptom resulting from organic changes on one side of the 
brain. An anaesthetic condition of the cornea has been alluded to. 

Convulsive seizures of different kinds are occasional evidences of the 
serious effects of alcohol. These may vary from simple spasm to a va- 
riety of convulsion which closely resembles a marked epileptic paroxysm. 
In fact the diagnosis is oftentimes very difficult. What I have said about 

^ Magtian considers that organic hemi-ansesthesia and general paresis are quite 
common results of chronic alcoholism, op. cit., p. 134. 

28 



434 CEREBRO-SPINAL DISEASES. 

the mental condition in acute alcoholism may be now applied. The hal- 
lucinations and lighter forms of sensory and mental aberration exist at 
different stages, but towards the end the condition is one of dementia of 
the most profound character, the patient being completely oblivious of the 
outside world, and of his duties to society. He is morally irresponsible, 
and the crimes he may commit are motiveless and dictated only by a dis- 
eased mind. 

Causes. — Chronic alcoholism follows the steady use of large quanti- 
ties of alcoholic liquors, but is rarely found among those who drink wine 
or malt liquor. The French, Italians, and Germans are, therefore, seldom 
affected in their own countries, especially outside of the large cities, where 
a very small amount of ardent spirits is taken. In England, Scotland, 
Ireland, and America the case is different, for in these countries there is 
no low-priced light beverage which takes the place of the wines and beer 
of the European Continent, which are drunk in preference to water. 
Without entering into the discussion of the effects of alcohol upon other 
organs of the body than those of the nervous system, it may be said that 
the condition known as alcoholism springs from a protracted use of large 
quantities of strong liquor, so that the nervous substance is deprived of its 
normal nutrition, the blood being charged with effete substances which 
should be eliminated by the kidneys, lungs, and skin. 

Delirium tremens is due generally to the direct action of a large quan- 
tity of alcohol, which produces overwhelming toxic effects ; while chronic 
alcoholism implies a structural degeneration due to the continued action 
of the alcohol itself, and to the vitiated blood. 

Delirium tremens may occur either from a sudden cessation of indul- 
gence, or in the midst of a prolonged debauch, most commonly, however, 
the latter. In some persons elimination goes on so perfectly that large 
quantities of liquor may be taken and disposed of without any profound 
effect upon the nervous system being produced. These individuals may 
drink to a point much beyond moderation, and still suffer no marked in- 
convenience, the alcohol seemingly affecting some other organ, which may 
be either the liver or kidneys, so that cirrhosis or degeneration of other 
kinds may take the place of the cerebral trouble in the beginning. 

Males are much more often affected than females, as the statistics of 
Magnan show : — 

Acute alcoholism (D. T.) 
Subacute '' 
Chronic " 

This fact has been confirmed by statistics collected by the Health De- 
partment of New York. During the year 1873, 45 deaths were reported 
from delirium tremens, but four of whom were females. It is probable 
that there were many more cases which were not reported as such. 





M. 


F. 


fl870 


. 35 


2 


tl871 


. 42 


2 


rl870 


. 216 


51 


11871 


. 159 


47 


ri870 
11871 


. 126 


11 


. 90 


14 



ALCOHOLISM. 435 

Women, however, though not so subject to chronic alcoholism as men, 
often drink to excess, and not rarely develop delirium tremens. This bad 
habit is confined chiefly to either extreme of society — the very lowest class, 
or the highest in the social scale. Among the latter the amount of pri- 
vate dram-drinking is astonishing ; and though the " skeleton in the 
closet " is carefully guarded by the friends of the patient, it is by no 
means uncommon for the physician to be called in to attend cases of de- 
lirium tremens in high life. 

Absinthe, which is extensively used in Paris, and is beginning to be 
introduced into this country, produces a terrible form of delirium tremens, 
in which mania is a marked feature ; and a form of epileptiform attack is 
also quite common. 

Alcoholism is much more often observed between the twentieth and the 
fiftieth year, and is very rare before that time. 

As to hereditary predisposition there is a great deal to be said, but 
when we attempt its consideration we depart from the immediate subject. 
Occupation and mental influences have much to do with the making of 
drunkards or hard drinkers. Barkeepers, and individuals exposed to se- 
vere weather, are commonly addicted to drink ; the one either feeling 
obliged to be convivial or indulging only because the liquor is so accessi- 
ble, and the other because he " needs something to keep out the cold." 
Mental depression, grief, and business worry are interesting in their social 
features, but do not strictly come within the scope of an article of this 
character. 

Morbid Anatomy and Pathology.— The prolonged use of alcohol 
is followed by marked changes in the structure of the nervous substance. 
In the early stages there may be found appearances which are ordinarily 
met with in uncomplicated cerebral congestion, viz., enlarged vessels 
injected meninges, and efi"asions of serum. These may vary greatly in 
their extent and appearance, and may be associated with a fatty degenera. 
tion of the vascular walls, patches of softening, or even little foci of indu- 
ration. The disease leaves its traces most indelibly stamped as meningeal 
thickening and opalescence, and perhaps encysted collections of blood, 
which have been described in speaking of pachymeningitis. The sinuses 
are engorged, and the dura mater may be adherent to its underlying mem- 
branes ; or they, in turn, may be in such close contact in spots with the 
cortex that their removal necessitates the tearing out of patches of super- 
ficial gray substance. The convolutions will be found to be atrophied 
and reduced in size, and the ganglia at the base are often greatly softened. 

Many observers, among them Carlisle and Percy, have found alcohol in 
the fluids in the ventricles. Besides these intracranial changes, the liver, 
kidneys, and stomach present appearances with which all pathologists are 
familiar. The arteries throughout the body are found to have undergone 
atheromatous degeneration, and this is seen in the brain to a very decided 
degree. As to the condition alluded to by various observers, viz., the 
mechanical change exerted directly by the contact of alcohol with the tis- 
sues, I think there has been much exaggeration. The sclerosis so often 



436 CEREBRO-SPINAL DISEASES. 

seen is much more probably the result of interstitial inflammatory change 
than a chemical transformation. 

The experiments made by Anstie/ Magnan,^ Percy, Marcet,^ and 
Motet* settle with great certainty the pathological processes which follow 
the toxic administration of alcohol. Anstie took a full-grown dog weigh- 
ing 10 lb. 4 ozs., and injected 6 ozs. of mixed alcohol and water into the 
fctomach at 1 P. M. No food had been taken for four hours previously. 

1.4 P. M. Auimal obviously affected ; staggers in walking, and fre- 
quently falls down. The hind quarters are weak, and skin of hind limbs 
insensitive. Kesp. 24 ; circulation, 140. 

1.6 P. M. Dog lies extended on the floor quite drowsy, but capable of 
being roused ; fore-limbs retain slight degree of voluntary power. Tongue 
protruded, and the dog " slavers " still. Skin about mouth anaesthetic ; 
conjunctiva sensitive. 

1.7.30 P. M. Animal falls on its side, comatose and snoring. Conjunc- 
tiva insensitive with other parts. Resp. 20 ; circulation, 184, tolerably 
strong. Ano-geuital region was sensitive to painful impressions. Pupil 
strongly contracted at first, but became dilated at 1.25, little sensitive to 
light ; anaesthesia remained ; eyes still insensitive ; continuous tremor of 
hind-legs began and continued for a short time. Respiration declined in 
frequency, and became gasping, and ceased at 3.5 P. M., two hours after 
the ingestion of the alcohol, the heart beating 64 per minute. It remained 
irritable for some minutes later. Much more complete and earlier coma 
followed the administration of larger doses. 

The continued toxic use of alcohol produces changes not only upon the 
nervous system directly, but secondarily through other organs which are 
primarily affected. A large quantity of alcohol taken into the system in- 
duces pathological changes somewhat after the following manner : A certain 
portion, quite small in amount, is promptly excreted, and maybe detected 
in the breath, urine, bile, and sweat, while the greater proportion remains in 
the blood, greatly altering its character and inducing a large number of 
interesting changes. Lallemand, Marcet, and various experimenters have 
found that the excretions contained much pure alcohol, and others have 
detected, by the chromic acid test, traces of alcohol forty-eight hours after- 
wards. Anstie declares, however, that but the merest fraction of the 
amount taken is eliminated in its unchanged form. In this conclusion he 
differs from the authorities I have quoted. The alcohol remaining in the 
blood is partially eliminated in its decomposed state (carbonic oxide and 
water), while a certain quantity remains. The internal organs are con- 
gested, notably the liver, kidneys, and lungs, so that excretion is very 
slowly performed, and the urine voided is scanty in amount, devoid of 
the chlorides, and rich in urates. The blood circulates sluggishly, and 

1 Stimulants and Narcotics, p. 3S5 et seq. ^ Op. cit., p. 116. 

^ De la folie causee par I'abus des boissons alcooliques, these de Paris, 1847. 
* Considerations generales sur I'alcoolisme, et plus particulierement des effets tox- 
iques sur riiomme par la liqueur d'absintlie, 1859. 



ALCOHOLISM. 



437 



contains fat and sugar. I have also found sugar in the urine, which pro- 
bably resulted from irritation of the medulla as well as certain disturb- 
ances of kidney and liver function. 

The abundance of carbonic acid requires double duty upon the part of 
the lungs, and consequently respiration becomes labored and quickened. 
The natural oxidation of the blood is seriously embarrassed, and elimina- 
tion is retarded most seriously. 

The nervous system of course suffers from this change in its badly nour- 
ished state. Degeneration of the nervous elements follows, and interstitial 
thickening and medullary metamorphoses take place, so that the loss of 
function is very great. The pneumogastric being implicated, the lungs 
and other organs are not properly innervated, and many of the curious 
evidences of such disorder follow. This is illustrated by the tendency to 
pneumonia which often exists as a feature of alcoholism. 

The sympathetic system is of course implicated. The actual presence 
of alcohol is attended by vaso-motor paresis, and a number of vascular 
changes probably follow. It might be well, before closing, to refer to a 
condition of the cranial bones noted by Lancereaux and others, A hard- 
ening and thickening is due to nutritive changes, which Anstie thinks is 
not a true hypertrophy, as the original texture of the bone is lost. 

Prognosis. — A table prepared by Mr. Neilson from the Registrar- 
General's report shows that the probable duration of life in individuals 
who have reached the 20th, 30th, 40th, 50th, and 60th years, and who 
have been either temperate or intemperate, is about the following : — 



Having reached 


Has an average chance 


But the intemperate have an average chance 


the age 


ot 


of still surviving 


of surviving only 


20 




44.21 years 


15.53 years, or 35 per ct. of the duration of 
life of the general population. 


30 




36,48 '' 


13.80 " " 38 '' " " 


40 




28.70 " 


11.62 " " 40 


50 




21.25 " 


10.86 " " 51 " " " 


60 




14.28 " 


8.94 " " 63 " " " 



This applies only in a general way to the subject, but is significant in 
showing how greatly the alcoholic habit diminishes the patient's chances. 
In regard to the prognosis of the actual attack, there is rarely any rea- 
son to fear a fatal termination unless the patient has had a number of 
previous ones. Coma and convulsions should be looked upon with grave 
suspicion, as they greatly diminish the patient's tendency to recovery. 
Chronic alcoholism is more unfavorable. Should the patient survive his 
immediate nervous trouble, it is very likely that disease of some other 
organ will carry him off. Cirrhosis is the most common of these, and the 
patient's mental condition may be for some time aggravated by choles- 
tersemia. Much depends upon his ability to reform ; and no assurance 
can be given that he will recover until this is accomplished. 

Diagnosis. — The only diseases for which alcoholism maybe mistaken 



438 CEREBRO-SPINAL DISEASES. 

are: 1. General paresis; 2. Sclerosis, and paralysis agitans; 3. Soften- 
ing ; 4. Dementia. 

1. General paralysis differs from delirium tremens in the fact that in 
the former the delusions are always pleasurable and exalted. The general 
paralytic is the king, the capitalist, the ruler of the universe ; the alco- 
holic patient is depressed, dejected, and sad. These differences, taken into 
consideration with the fact that the patient suffers from anorexia, that his 
face is flushed, and the conjunctivae red, ought to settle the real nature of 
the trouble. Anstie^ alludes to the presence of acne as a pathognomonic 
sign. Chronic alcoholism may very closely resemble general paresis, 
but there is more proper dementia in the latter. 

2. Sclerosis and paralysis agitans are sometimes confounded with chro- 
nic alcoholism when there is much disturbance of co-ordination. The 
tremor and in co-ordination are much greater during voluntary action, 
however, in the first conditions, and there is rarely any mental disturb- 
ance in either. 

3. Softening resembles chronic alcoholism, but the paralysis and 
speech disturbance are much more pronounced, there generally being 
aphasia, and the headache besides is quite different from that of alcohol- 
ism. 

4. Senile dementia may make the diagnosis somewhat difiicult. The 
previous history of the patient, however, will generally clear away any 
doubts that may arise. 

Treatment. — The physician's first attempt should be to prevent the 
patient from further indulging his depraved aj^petite. How this is to be 
accomplished depends very much upon his surroundings, temperament, 
and condition. If the attack arises during a debauch, I prefer to cut off 
at once the supply of alcohol, unless he is utterly prostrated, If the at- 
tack occurs after cessation, we may then give small quantities of stimu- 
lants, and " taper off." Should he be irritable and excited, immediate 
recourse to sedatives and hypnotics should be had. I have great faith in 
the bromides, lupulin, or simple remedies of this class. Fifteen or twenty 
grains of the bromide of calcium, given in a drachm of the tr. lupulin 
twice or three times a day, is often sufficient to quiet the nervous state. 
A good cathartic which shall increase the action of the liver, and hasten 
elimination of the alcohol, is an early form of treatment which is gene- 
rally recommended. Should the insomnia be troublesome or the delirium 
violent, we may administer either the bromides, or the mono-bromide of 
camphor, which I make the claim of being the first to use for 
this purpose. It may be given in pilular form, made up with confection 
of roses, in doses of five grains every hour until sleep is produced. The 
bromides of calcium or sodium in thirty grain doses every two hours 
sometimes succeed, or, better still, they may be combined with chloral 
hydrate, so that the patient shall take fifteen grains of each every two 
hours until the excitement subsides. Cannabis indica has enjoyed great 

^ Article on Alcoholism, Eeynolds's System, American Edition, vol. i. p. 677. 



NICOTINISM. 439 

popularity in the treatment of this trouble, and should be given in doses 
of from one-half to one grain of the extract. Should the maniacal ex- 
citement be intense, I know of no better remedy than morphine adminis- 
tered hypodermically, bat not by the mouth, as it may lie unabsorbed for 
some time with producing any effect ; and the physician may be tempted 
to give still more than the ordinary dose, when to his surprise absorption 
takes place, and its cumulative action follows. Digitalis has been recom- 
mended in large doses, and Anstie preferred the powder because the alco- 
hol of the tincture interfered with the proper action of the drug. I am 
inclined to think that the application of digitalis stupes to the lumbar 
region and the abdomen favors kidney action, and does more good than 
when the medicine is given by the mouth. 

It is of importance that the action of the skin and bowels should be 
increased. For the first object, small doses of tartar emetic assist the 
emunctory action of the skin, while the compound jalap powder induces 
copious and watery discharges from the bowels. Cold to the head, either 
by ice-bags or cloths wet with ice-water, blisters to the calves, and local 
abstraction of blood may be resorted to in violent cases. As to food : 
when the worn-out stomach refuses all ordinary articles of diet, it will 
rarely reject iced milk, which may be given in all cases. After a while 
soups, nutritious broths, or bouillon made from beef, or Valentine's beef 
juice, or Borden's extract of beef, either of which is preferable to the 
Liebig extract on account of the nauseous taste of the latter, may be 
given in liberal quantities. Small doses of carbonic acid, seltzer, or 
Apollinaris water, or coffee may be administered before eating, and gently 
stimulate the stomach, in this respect taking the place of the drams. 

The patient's nausea may be corrected by the aromatic spirits of ammo- 
nia, or bismuth and morphine, the latter in very small doses. 

In chronic alcoh(;lism the aim of the physician should be to restore the 
normal action of the viscera ; to stop the supply of drink ; and to freely 
administer the various preparations of iron, quinine, and phosphoric acid, 
as well as cod-liver oil. I have found that dialyzed iron is well borne by 
the irritable stomach, does not constipate,and is therefore an excellent 
remedy. This may be given with tr. digitalis and tr. nux vomica. 

NICOTINISM. 

"When the nervous system is subjected to the influence of tobacco in ex- 
cessive quantities a train of symptoms may be manifested indicating a con- 
dition of affairs that may ultimately assume a serious character. While 
I believe tobacco to be one of the most valuable articles of comfort we 
possess, I every day am made aware that in an insidious way it produces 
nervous disorders which are sometimes quite as formidable as those caused 
by alcohol. I have found in more than one case of general paresis that 
the immoderate use of tobacco, had, in those of unstable nervous tem- 
perament, all to do with the development of the disease. I have no in- 
tention, however, of entering into the discussion of its general bearings in 
relation to public health and the morals of the community, for these sub- 



440 CEREBRO-SPINAL DISEASES. 

jects have been frequently dipcussed by popular reformers — and not 
always temperately or truthfully — but I will briefly call attention to the 
nervous expression of chronic tobacco poisoning. 

Symptoms. — The question of tolerance, in connection with physical 
development ; the effect of the constant use of tobacco upon the nervous 
individual — the possessor of the insane neurosis, perhaps — enter largely 
into the genesis of nervous symptoms. 

In persons of full habit, of phlegmatic temperament, and fat-making 
tendency tobacco may be used in considerable quantities and quite con- 
stantly without other than trifling effect, and in the rheumatic diathesis 
it is positively beneficial. In the spare, nervous individual the case is 
different, and the careless and continuous use of tobacco often produces a 
train of motorial and sensorial symptoms of varying grades of gravity. 
Both the voluntary and involuntary muscles may be affected, and atonic 
action of the unstriped muscular fibre result in a variety of cardiac and 
digestive disturbances. 

The action upon the heart is decided, there being great feebleness and 
inequality of the pulse, and as the brain becomes the seat of chronic 
ansemia we find dizziness, headache and melancholia, besides a variety of 
light mental troubles. The muscular tissue of the stomach, intestines 
and lower bowel are enfeebled so that slow digestion and loose evacua- 
tions are consequent. 

The production of general muscular weakness is a very conspicuous 
manifestation of the depressed tone of the nerve centres. These may be ex- 
pressed either in tremor, slight paresis, or an epileptoid condition ; the 
tremor, however, is the most familiar of all disorders of motility. 

It may be unilateral, but is usually found on both sides, the upper ex- 
tremities being more often its seat than the lower, and like the same mo- 
torial disorder seen in alcoholism, and among opium eaters it may be 
overcome for the time by recourse to the cause. It is essentially the 
tremor of debility, and has no very regular character. If the smoker ex- 
tends his hand so that it is in a somewhat constrained position, he will 
notice that some fingers are more agitated than others, notably the second 
and third. 

An advanced grade of motor feebleness is expressed in paresis, but 
rarely by paralysis, so far as complete and diffused anaesthesia is con- 
cerned. Erb, under the head of toxic spinal paralysis, speaks of the 
influence of tobacco in its production, and says that it causes lasting 
paralysis when the toxic action is slow and repeated, and much more 
rapidly than when acute. There is usually diminution of electro-muscular 
contractility. Various other disorders of motility are shown in local 
spasms, and among them are painless facial twitchings and blepharo- 
spasm, which may be very distressing ; spasms of the limbs and starting 
during sleep. Not a small number of cases of chronic tobacco poisoning, 
as I have said, end in the direct production of serious organic disease 
of the brain, and symptoms in many respects similar to those of cerebral 
softening or general paresis will be expressed. The pupil presents no 



NICOTIXISM. . 441 

constant appearance that may be considered important. Some authors, 
among them Taylor, and Woodman and Tidy hold that it is dilated in 
acute poisoning, while Pereira and Bartholow, say contracted, but in 
chronic nicotinism it is usually dilated. The urine is copious and loaded 
with earthy phosphates. Various dyssesthesia are common in chronic 
nicotinism. The patient calls attention to tinnitus, "tightness about the 
throat," '-pains beneath the ears," as well as intercostal pains, coldness 
of the feet, crawling sensations, and a sense of feebleness, especially in 
the morning. 

Amaurosis is one of the indications of anaesthesia. ^Drysdale reported 
the cases of two young men who became amaurotic from the continued 
use of tobacco, in one case the man taking but half an ounce of tobacco 
a day. ' Masselon in an admirable thesis refers to the production of color 
blindness, one of his patients being unable to tell a piece of silver from 
apiece of gold, and in all cases the patients seemed to lose the faculty of 
distinguishing yellow and red from other colors. 

^Webster, in a very careful paper, has called attention to the amblyo- 
pia produced by tobacco, and fully believes that tobacco alone may give 
rise to this ocular trouble. In seven out of twenty cases he found inci- 
pient atrophy of the optic nerve. In 18 of Webster's cases alcohol and 
tobacco were used to excess, and in one case tobacco was used excessively 
from ten to fifteen years, and alcohol moderately, and an occasional glass 
of gin was taken. In one case in which the amblyopia seemed to be 
wholly due to the abuse of tobacco, the vision rose from 2^0 to 70 in 
each eye when the patient abstained from its use, and received appropri- 
ate treatment. Dr. Ely takes a more conservative view of tobacco 
poisoning as a cause of amblyopia. 

Cutaneous hypertethesia or anaesthesia are by no means rare symptoms 
of chronic tobacco poisoning. I have in patients repeatedly found anaes- 
thesia of the lips and tongue, and in one subject smell was abolished, and 
not restored until the patient was subjected to a course of strychnia. 
Tactile sense is sometimes blunted, and especially is such the case in the 
tips of the fingers. aSTeuralgic pains are by no means uncommon, and are 
perhaps among the early sensory troubles. These pains may counterfeit 
those of early locomotor ataxia, and create great misery. In other cases 
there may be cardiac neuralgia, resembling in many respects the pain of 
angina pectoris. So grave is this symptom that even medical men who 
smoke to excess often believe themselves to be the subjects of this afiec- 
tion. Vague muscular pains, shortness of heart, and fatigue after slight 
exertion all come in for a share of our attention. 

The mental expressions of nicotinism are exceedingly variable, and 
may consist in the beginning simply of a change in the temper and dis- 
position, evinced by irritability, and accompanied by loss of memory, 
irresolution and hypochondriasis ; or in a graver form we may find actual 

1 British Medical Journal, Sept. 5, 1874. ^^hese de Paris, 1S72. 

3 Medical Eecord, Dec 11, 1880. 



442 CEREBRO-SPINAL DISEASES. 

symptoms of insanity, illusions, hallucinations and delusions either insane 
or otherwise, attacks of extreme excitement amounting to mania, or per- 
haps mania itself. 

^ Bucknill and Tuke speak of tobacco poisoning in the causa,tion of 
insanity, and ^ Kirkbride reported four cases of insanity due to tobacco. 
^Skae reports a case of mania produced by tobacco, and Continental 
literature contains other observations. 

The skin is usually muddy in color, and the mucous membrane of the 
tongue of an excessive smoker presents, according to some observers, the 
appaarance as if it had been brushed over with nitrate of silver. 

Causes. — Tobacco, when used to excess, does far more harm in some 
ways than others; and the purity of the substance and the method of its 
consumption greatly influence the troubles that may follow. * Anstie 
says : " There are a few whom no amount of care and skill exercised in 
taking the tobacco, nor any moderation in the dose used, can save from 
unmistakable poisoning whenever they indulge in it. These cases are 
rare, and they should be carefully separated from the evil results which 
are produced by mere unskillfulness in smoking." Chronic poisoning 
arises from certain bad habits, and these maybe enumerated as: 1. 
Smoking when the stomach is empty. 2. Using several cigars in succes- 
sion. 3. Inhaling the smoke of cigars or cigarettes. 4. Smoking only a 
pipe in which "the nicotine has collected. 5. Swallowing the saliva. 
Among: smokers it is found that the nervous effects are more easily pro- 
duced in the early part of the day. 

It is difficult to say just how much tobacco is harmful. In a case re- 
ported by ^Gmelin, seventeen or eighteen pipes were smoked in quick 
succession by two men with fatal results. 

The use of snuff by women in the manner known as " dipping," is hap- 
pily becoming rare in this country. I have seen several examples of this ■ 
kind leading to chronic poisoning. A stick, tooth-brush, or some such 
article, is dipped in fine snuff, and the gums and inside of the mouth are 
rubbed therewith. The toxic effects of tobacco are produced in a short 
space of time and are said to be pleasurable. I have found this custom to 
be prevalent among prostitutes, but it is by no means confined to them. 
In the case of a lady of refinement and social position, I found that a 
peculiar train of obstinate nervous symptoms were due to " snuff dipping," 
and search disclosed small parcels of snuff under her pillow and beneath 
the mattrass of her bed. 

Cigarette-smoking, which has increased to an incredible extent of late 
iu this country, is much more apt to give rise to nervous symptoms, be- 
cause of the tendency to almost constant indulgence, and the inhalation of 
the smoke. 

1 Manual of Psychological Medicine, p. 100. 

2 Annual Report of Philadelphia Hospital for the Insane, 1880. 

3 Ed. Med. Journal, Jan., 1856. 

* Stimulants and Narcotics, p. 138. 

° Reported by Woodman and Tidy, p. 379. 



NICOTINISM. 443 

Pathology. — According to ^ Anstie, tobacco is a narcotic-stimulant, 
and he classes it with tea and coffee. The poisonous effects, as agreed by 
most authors, are excited in two ways : 1st. In interfering with the pul- 
monary circulation, retention of carbonic acid gas, and blood-poisoning- 
2. A direct influence from the nervous tissue itself. The motor-nerves 
seem to suffer abasement of function, though the muscular irritability is 
not disturbed. 

There seems to be some doubt as to the poisonous agent in tobacco. 
Vogel says that the toxic properties of tobacco-smoke are due to the pre- 
sence of sulphide and cyanide of ammonia. ^Eulenburg could not find a 
trace of nicotin (Woodman and Tidy), but he and Vohl believed the poi- 
sonous substance to be pyridin (C 5 H 5 N.) and parvolin (C 9 H 13 N-) 
^Huebel, however, has found the amount of nicotin in one cigar sufficient 
to produce convulsions and death in a frog. 

There is undoubtedly in tobacco-smoke a certain amount of nicotin and 
other alkaloids in combination with alkaline bases. In gouty subjects, 
therefore, the use of tobacco cannot fail to be beneficial, when smoked in 
moderation. 

In small quantities tobacco slightly exhilarates and increases the action 
of the heart, and one cigar may effect a prompt increase of thirty or 
forty pulse-beats — a secondary depression follows, however. 

* Headland ascribes the comparatively light narcotic effect of tobacco to 
its prompt elimination by the kidneys, and says : " It is only not a poi- 
son because slowly taken into the system in small amounts and eliminated 
j)ari passu." In those individuals in whom, through disease of the ex- 
creting organs, the poisonous elements are not promptly removed, the 
production of nicotinism is much more prompt. The occurrence of ver- 
tigo is probably often due to a cumulative effect which occasions cardiac 
weakness. The cerebral effects of prolonged nicotinism are occasioned 
by the continued malnutrition of the brain tissue. 

Prognosis and Treatment. — Nearly all the alarming symptoms 
can be immediately moderated or cut short by prompt discontinuance, 
and recourse to nux vomica or its alkaloid. The analysis of tobacco by 
^Schlossing and others, with regard to .the quantity of nicotine has some 
bearing upon the evil effects attending its immediate use. 

In 100 parts of Virginia tobacco Schlossing found 6.87 parts of nicotine 
In the same quantity of Kentucky tobacco there were 6.09 ; in French 
tobacco, 4.94 — 7 ; Maryland, 2.29 ; Havanna, less than 2. In dry snuff 
there is 2 per cent. ; in moist, 1.3. 

Those who use tobacco are rarely inclined to acknowledge its bad eflects 
but to attribute them to other causes ; but, as Taylor says, " The argument 
that cases cannot be adduced to show direct injury to health proves too much 
— for a similar observation may be made of the habit of opium-eating." 

^ Stimulants and Narcotics, p. 100. 

■' Viertljahrschrift f. Ger. Med. N. F. xiv., p. 249, and Woodman & Tidy, p. 379. 

3 Centralblatt, Oct. 5, 1872. ^ Aciion of medicines, p. 269. ^ Quoted by Taylor, p. 771. 



444 CEREBRO-SPINAL DISEASES. 

For the person who presents decided nervous symptoms traceable to 
tobacco, no better treatment can be suggested than the continuous use of 
a tonic containing iron, quinine, and strychnine, — such, perhaps, as the 
following: 

R. — Strychnise Sulphas, gr. i. 

Quinise Sulphas ^\. 

Tr. Ferri. Chloridi. ...... ^v. 

Acidi Phosp. dil. ) ^z- 

Syr. Limonis j ^^3^' 

Sig. : — One teaspoonful in water thrice daily. 
Strychnine alone, in small, repeated doses, or perhaps combined with 
digitalis, is useful. In amblyopia many authors, among them AVebster, 
recommend the hypodermic use of strychnine. From 1-60 to 1-24 gr. may 
be given at a dose. 

HYDROPHOBIA. 

Synonyms. — Rabies canina; Paraphobia; Lyssaphobia (?). 

The name adopted to express that form of nervous trouble which some- 
times follows the bite of a rabid animal is an evident misnomer, as the 
definition of the term signifies " a dread of water." As this is but one 
symptom, and by no means a constant one, the first synonym is much 
more expressive and appropriate, and is in every way preferable to that in 
general use. 

Symptoms. — 1- Period of Incubation. — After the receipt of the bite, 
which may produce an extensive wound, or, as is the case sometimes, an 
insignificant scratch, a period of time extending from a few months to 
several years may elapse before the appearance of the second stage. The 
wound may heal by first intention, giving rise to no inconvenience, or 
there may be redness and neuralgic pain. A history of this kind is usu- 
ally given by the patient, and is based upon an exaggerated statement of 
the actual facts, which arises from a disordered imagination, while his story 
of the accident and of his subsequent symptoms is tinctured with a deci- 
ded flavor of romance. Nervous derangement dependent upon fear, di- 
gestive disorders, mental worry, and others of the same category, generally 
characterize this first stage. 

2. Period of Invasion.— At the end of the period of incubation, the 
first alarming symptoms noticed are those connected with the cicatrix, 
which becomes painful and tender, and at the same time there are pains 
which dart along the nerves in the vicinity. There are next generally 
headache and a sense of epigastric oppression, with constipation, broken 
sleep, and a feeling of general discomfort. At the end of two or three 
days, during which the patient suffers intensely, we may expect the appear- 
ance of the next stage. 

3. The Period of Development. — With aggravation of the symptoms 
just enumerated, we find added thereto a sense of constriction about the 
throat, irregular and quickened respiration, rigidity of the muscles of the 
neck, discomfort in deglutition, and spasms, which begin in the muscles of 



HYDROPHOBIA. 445 

the throat and back of the neck, and gradually invade those of the back. 
The spasms give rise to much pain, which is sometimes spinal and at others 
muscular. The patient is at this stage delirious and flighty, and gene- 
rally has delusions in which dogs play an important part. The difficulty 
of swallowing, which next follows, is not so great when solids are taken. 
Fluids, on the contrary, seem to produce an aggravation of the spasms, 
and the mere sound of splashing or trickling water will excite a convulsive 
seizure. To add to the sufferings of the patient, there is excessive thirst, 
which is very distressing. His face becomes dusky, and his eyes promi- 
nent and wild. He tosses from side to side if placed in bed, the saliva 
running from the angle of the mouth in a viscid stream. Towards the 
end of the disease this secretion becomes thicker and mixed with mucus, 
and it collects in the trachea and bronchi. These symptoms may last 
two or three days, while in the meantime the reflex excitability becomes 
so great as to precipitate a convulsion under the least stimulus. The pulse 
is rapid, the headache more severe, the air-passages become filled, and 
respiration is greatly interfered with. The convulsions are readily pro- 
duced by blowing upon the patient, or by jarring him, or even by slam- 
ming the door. At this stage he becomes partially unconscious, is quite 
delirious, and very much agitated. Previous to death there is a marked 
rise in the temperature, and in one case I saw, the history of which I shall 
presently relate, the temperature rose to 103"^, and I believe there was even 
a subsequent rise. 

Death occurs in two or three days in most cases, but it may be delayed 
a day or two longer. Incontinence of urine and feces precedes the end ; 
the immediate cause of death being asphyxia from spasmodic stenosis of 
the larynx, or obstruction of the air-passages by mucus. I had the 
privilege of seeing one case at the request of Dr. Augustus Viele, of this 
city, which was subsequently reported by Dr. Hadden.^ 

Through the courtesy of Dr. Hadden and Deputy Coroner Leo, I was 
also enabled to observe the post-mortem appearances of the brain and 
cord. Dr. Hadden describes the case so minutely that I shall mainly use 
his own words. 

" On the 24th ultimo, at 8.30 P. M., I was called to attend a young man 
named Wm. McCormick, residing at Xo. 309 East 51st Street, a native of 
this city, aged 26 years, athletic in appearance, of usually good health, 
nervous temperament, and of moderately temperate habits ; by occupation 
a driver of an express-wagon. He was in bed, complaining of nervous- 
ness,, soreness in his neck and throat, strange feelings of tightness around 
his chest. His countenance was anxious, pupils of his eyes were dilated, 
and his general appearance was like one who was in fear of impending 
danger, and not in extreme pain. He told me that his throat was so sore 
that he could not swallow anything — not even water. This, he thought, 
was due to some simple medicine he had taken, and not to any serious 
ailment. I noticed his throat was not swollen on the outside, and that his 



^ Journal of Psychological Medicine, Mav, 1870, p. 80. 



446 CEREBRO-SPINAL DISEASES. 

voice was whining, and unlike a person suifering from any ordinary sore- 
ness within. I, however, examined his throat within, but found nothing 
to account for this difficulty ; it was perfectly healthy in appearance. 
His pulse, respiration, and temperature were normal, excepting an occa- 
sional sigh. I observed, also, a little disposition to hack and spit, but in 
no way troublesome. He complained also of thirst, but said he could not 
drink, he knew, for the very sight of water made him shudder. I told 
him his throat was not sore, and urged him to try. He assented, and 
water was accordingly brought, which, at sight, caused a violent spasm. 
He threw himself around in the bed, forward and backAvard, and told the 
party to take it away at once, as it would kill him. He immediately af- 
terwards called for the goblet, and said he was very thirsty and must 
drink, seized it, and with a violent effort succeeded in taking a single 
swallow, which was followed by a severe convulsive shudder and contrac- 
tion of the muscles of the neck and chest." Dr. Hadden ascertained the 
fact that he had been bitten by a dog, and then inquired about the symp- 
toms antecedent to his visit. " Weduesday and the two preceding days 
he was complaining of general lassitude and nervousness ; had not been 
able to sleep at night ; was thirsty, and had drunk a great deal of water; 
had eaten but little ; appetite very poor, and on Wednesday afternoon he 
seemed to be growing worse. He went out upon the street, but soon re- 
turned, saying that it was very chilly, and he could not stand the air at 
all. While taking a cup of tea at 6 P. M. the same evening, he first 
showed signs of difficulty in swallowing. Shortly afterwards, as he was 
going to the kitchen, he Was met by a draught of cold air, which so stag- 
gered him that he nearly fell ; he then went to bed, where I found him. 
After giving the necessary caution to the family, I ordered fifteen grains 
of bromide of potassium to be given every hour. I left, and returned at 
10.30 p. M. . . . Found him in about the same condition I had left him, 
only his pulse was irregular, and his spasms more frequent. The saliva 
was a little more troublesome, and he also could not swallow without great 
difficulty. I was called again at 2.30 A. M., the messenger stating that 
the patient had become very violent, and that they were unable to restrain 
him. I went immediately. . . . Found him in a frightful state of excite- 
ment; had. broken down the bed, and was struggling with his attendants 
to get at liberty. He was shouting and crying out to them to let him go, 
and called for water, which, when brought, he could not drink. His mind 
was clear, and he knew all those around him ; was spitting a viscid saliva, 
but was careful not to spit upon any one, not even on his clothes. It was 
so abundant that his attendants were obliged to wipe it from his lips. Dr. 
Leavitt and myself, after viewing the case in all its aspects, concluded to 
inject in the tissues of the leg half a grain of morphine and one-sixty- 
fourth of a grain of atropine in solution, which was done at 3 A. M. by 
Dr. Leavitt. We carefully watched the effect till 3 30 A. M,, when, his 
violence having in no way abated, another injection was given in the 
same part of three-eighths of a grain of morphine and one-eighth of a 
grain of atropine, which in some degree produced the characteristic effect 
of morphine, and very clearly the appearances of the atropine ; for, not- 
withstanding he was struggling violently, the saliva, which had been very 
troublesome, was completely dried up ; so much so that the patient re- 
marked that he was very thirsty, and his ' mouth felt as if he had been 
chewing a brick.' Fifteen drops of chloroform were then injected, with 
no effect whatever, unless to weaken his already weak and frequent pulse. 



HYDROPHOBIA. 447 

At 4.15 A. M. three-eighths of a grain of morphine were a gain intro- 
duced under the skin without atropine. This quieted the patient, so that 
he was easily restrained, and he remained in this condition from 4.30 till 
10 A. M., when the effects had so far passed off that the attendants were 
alarmed at his violence and the abundance of saliva that he was spitting 
from his mouth. At 10.15 A. M. three-eighths of a grain of morphine 
in solution were injected in the tissue of the thigh, which served to temper 
down the increasing violence of the spasms, but did not stop the flow of 
saliva. I accordingly, at 10.45 A. M., injected three-eighths of a grain 
of morphine and one-fortieth of a grain of atropine, which had the de- 
sired effect of producing the quieting effect of the morphine and the spe- 
cific effect of the atropia on the salivary glands. The poisonous effects 
of the morphine and atropia were at no time apparent. He died at 4.15 
P. M. June 26, 1874, about twenty-four hours after the first spasm." 

I saw him at three o'clock on the afternoon of the 26th day, and 
found him lying upon the floor bound with twisted sheets, the ends of 
which were held by his attendants. He was very violent, and, though 
there were no very marked convulsions, he seemed to be quite 
rigid, and his forearms were flexed during most of the time. He was 
semi-comatose, and groaned occasionally, but took no notice of those 
about him, and did not speak. His respirations were quick, and there 
was a rattling sound produced in his throat with each expiration and in- 
spiration. A quantity of quite thick mucus and saliva was spat up dur- 
ing my visit, and there seemed to be a very free secretion of this sub- 
stance. The pupils were widely dilated, and as far as I could judge there 
was no marked elevation of temperature.^ 

Recent cases of hydrophobia have been reported by Francois,^ Ed- 
wards,^ Smith,* and Hanscom.^ The case of the latter is so interesting 
and so graphically detailed, that I shall take the liberty of giving it in 
full. 

On the morning of the 20th November a good-natured pet spaniel, 
which had never been known to snap at any one, suddenly and without 
any provocation sprang at his mistress. His master whipped him, and 
he was left in the cellar of the house until the time for his dinner, ^yhen 
eating it in the company of a pet cat, as he had been accustomed to, 
without ever having molested her, he suddenly seized the cat and threw 
her across the room. The owner reached out his hand to catch the dog, 
when the latter caught him tightly by the wrist and inflicted a deep 
wound, biting him three times ; the skin became lacerated while making 
an effort to shake him off. It was supposed at the time that the dog was 

1 In this case the newspapers were filled with sensational accounts of the patient's 
illness, and an attempt was made to prove that the dog was not mad. It is needless 
to say that such was probably not the case, and it is to be regretted that the dog was 
never found. 

'^ Bost. Med. and Surg. Journal, May 17, 1877. 

3 Ibid., March 15, 1877. 

* Ibid. 

5 Ibid., April 19, 1877. 



448 CEREBEO-SPINAL DISEASES. 

irritable from the whipping which he had received in the morning, and, 
as he expected another for snapping at the cat, defended himself by bit- 
ing. Half an hour after, the patient applied to me for treatment, and be- 
lieving it to be too late for incision or cauterization to be effective, and as 
there was no history of hydrophobia, I dressed the wound with a solution 
of carbolic acid. It healed readily, and the patient attended to his busi- 
ness as usual in four or five days. Soon after the infliction of the bite 
the dog disappeared and he did not return for thirty-six hours ; nothing 
could be ascertained of his whereabouts or of his behavior during that time. 
When he returned he was very much exhausted, aud had the appearance 
of having been severely beaten. From what I can learn of those who saw 
him he gradually grew weaker, apparently losing the use of his legs, espe- 
cially the hind ones, which he would drag after him. He died quietJy, 
with his head in the lap of his mistress, without having had a convulsion, 
excessive flow of saliva, or tremors. On the 13th day of January (fifty- 
four days after the injury), the patient b( gan to have shooting pains in 
the forearm, but not especially localized. They did not radiate from the 
cicatrix, and there was no change in the appearance of the latter' On the 
following day the pain had increased so much that he required one-sixth 
of a grain of morphia to relieve him ; it was given subcutaneously, an I 
was repeated the next morning. After that there was very little pain in 
the arm, and no appreciable change in the pulse or temperature. He was 
despondent, and stated on the morning of the 15th that 'he felt sick and 
used up all over ;' he was obliged to go to bed in the afternoon, and then 
for the first time began to have some difficulty in swallowing. This symp- 
tom was not manifested by an attempt to drink water, but during an effort 
to swallow some herb tea which he was accustomed to take when ill, aud 
which he believed would relieve his bad feelings. There w^as no trismus ; 
he was quiet and inclined to doze. At 5 P. M. Dr. H. H. A. Beach saw 
the patient with me, aud agreed that the history of the case in connection 
with the symptoms then existing indicated the probable development of 
hydrophobia, and an unfavorable prognosis was given to the patient's 
brother, who promised not to communicate it to the patient or his friends 
until the disease should be fully declared. His pulse at this time was 102, 
and the temperature in the axilla 102° F-, face flushed, tongue coated. 
The cicatrix presented no unusual appearance, nor was it tender. A dark 
room was agreeable to him, but on raising the curtains the light did not 
disturb him in the least. He was perfectly rational, and had some thirst, 
but no sore throat. He made an attempt to swallow a teaspoonful of milk, 
but was obliged to give it up from the moment that the fluid touched his 
lips. Immediately after this attempt unmistakable spasmodic contraction 
of muscles betw^een the chin and sternum was observed. Mentally the 
patient was perfectly clear, and not disturbed by the unsuccessful attempt 
at swallowing fluids, but said he would try it again when he should be 
more thirsty. This symptom, excepting when he swallowed teaspoonful- 
doses of medicine, continued until his death. He was obliged to relieve 
his thirst by sucking ice and snow through a napkin. The air from a 
fan or from adjusting the bed-clothing caused a shudder. Occasional 
sighing w^as noticed after the second day ; it grew deeper and more fre- 
quent until the end. When disturbed from any cause, his respiration 
was of a spasmodic character, so much so at times as to interfere with his 
speech. 

On the following morning (the 16th) his pulse was 98, and mild de- 



HYDROPHOBIA. 449 

liriura first developed ; this also coDtinued until his death. He was easi]y 
controlled throughout the disease. He became very suspicious of the 
people about him, believing that they were attempting to make hioi the 
victim of practical jokes, then of being poisoned. One hallucination 
was continuous from the time that the delirium first developed : he 
thought that some one had thrown a dirty powder on him, and he was 
continually making efibrts to shake it ofiT from himself and his clothing. 
He was also very cross and dictatorial, but showed no disposition to snap 
or bite. 

Between four and five P. M. on the 18th he began to have spasmodic 
contraction of the muscles of the chest, larynx, and throat; some of them 
lasted nearly a minute, and prevented him from taking an inspiration. 
He also had a profuse discharge of saliva sufficient to wet his clothing 
through from his chin down to his hips. The spasmodic contractions con- 
cerned in respiration exhausted him rapidly, and he died quietly at 8 1-5, 
while sitting up in a chair. This position became necessary from the fact 
that he could not lie on his side, and if on his back the saliva accumulated 
so rapidly that it obstructed his respiration. For the last twenty minutes 
before his death there was no spasm. He lived five days after the first 
general symptom. At no time was he disturbed by the sound of ringing 
bells or running water. Morphia in one-fourth-grain doses, and chloral 
and bromide of potassium in fifteen-grain doses of each at the same time 
were given as needed. Anaesthetics were not required. At the solicita- 
tion of his friends he was allowed to take a pill, the prescription for 
which was said to be one hundred years old and to have cost originally 
five hundred pounds. It had the reputation of curing and preventing 
many cases of the disease. No change in his symptoms could be attributed 
to its action, nor could its composition be ascertained. It was given as a 
placebo, on the chances that an hysterical element existed in this case ; 
that whatever offered encouragement to the patient without the possi- 
bility of injury in his hopeless condition was justifiable, but so far as the 
evidence furnished by one case is of value its inefficacy was demonstrated. 
The permission of his friends for an autopsy could not be obtained. The 
particular symptoms of the disease which were not observed in the dog 
when seen might have existed during the thirty-six hours that he was absent. 

The proximity of the wound to the ulnar nerve and its character 
(punctured and lacerated) suggested the consideration of tetanus as an 
explanation of the symptoms ; the latter seemed to be fairly excluded, 
however, on the ground that delirium was continuous from the third day 
of the attack, and that at no time did trismus or any other form of tonic 
spasm exist ; the profuse discharge of saliva was also corroborative of this 
view. The unquestionable existence of repeated attacks of laryngeal 
spasm ; the fact that the symptoms developed after a considerable interval 
had elapsed from the date of the injury ; that for three hours previous to 
his death, and after he became wholly unconscious, marked spasms of the 
chest and throat occurred at intervals of from three to five minutes ; that 
death occurred as a result and within five days following the development 
of symptoms characteristic of the disease, reasonably offset a theory that 
the hydrophobic symptoms were simulated by an hysterical man. 

In Smith's case the period of incubation was about two months, and the 
paroxysms were ushered in by vomiting, fear of water, and febrile symp- 
toms. On the third day of the disease he became delirious, and on the 
29 



450 CEREBRO-SPINAL DISEASES. 

fourth died. The sound made by the patient, which is so often compared 
to the bark of a dog, was likened by the author to that made by a croupy 
child. In Edwards's case, the period of incubation was about five months. 
The injury was insignificant, but with the invasion' of the disease there 
was pain in the cicatrix which extended up the arm. In this patient 
there was also dread of fluids, especially water. On the second day the 
convulsions began. The same day she spat up bloody mucus. At the 
end of sixty hours from the first local pain she died. 

Causes. — The circumstances which concern the etiology are still 
enshrouded in mystery. Some authors are of the opinion that rabies may 
be communicated by a dog that is not mad, and cases are brought forward 
to prove this theory. I cannot agree with this, for it seems to me highly 
improbable that there should be so few cases of this disease if the bite of 
a non-rabid animal can inoculate an individual. Bouley states that in no 
way can the disease be transmitted other than by inoculation with the saliva. 
In this statement he receives the endorsement of Magendie and others. 
Another point remains to be answered, and this is in regard to the trans- 
mission of virus from one person to another without the second person 
being bitten. Fleming has given an example which shows that this may 
take place. 

In the spring of the present year I was subpoenaed to serve as a jury- 
man in the case of a boy who had died of rabies. At about the same 
time another death occurred which the attending physician said was 
simply the result of fear, and not of hydrophobia. A careful inquiry and 
examination of witnesses revealed the following history, which I think 
proved beyond a doubt that the cause of death in both cases was the 
bite of a rabid cat. This cat had found her way into a stable on Thirty- 
fourth Street, and had bitten a horse. This horse afterwards died in con- 
vulsions, and from all I could learn the cause of death was hydrophobia. 
In an adjoing yard the cat bit one of the boys, who also died, and in a 
few days afterwards bit the other boy, whose inquest we attended. Both 
of these victims died within a short time of each other. In one of these 
cases there was but a slight scratch. 

Morbid Anatomy and Pathology. — ClifiTord Albutt,^ Meynert, 
Elder,^ and others have made autopsies, and still there seems to be very 
little light thrown upon the pathogeny of the disease. Albutt found en- 
largement of vessels in the cerebral convolutions, pons, medulla, and 
spinal cord, and granular disintegration. Elder found absolutely nothing ; 
and the results of the search of Lockhart Clarke who examined parts 
of the brain, medulla, and cord, were equally negative. 

Kolesnikoff^ reported the appearance of the nervous centre in ten dogs 
that had died of hydrophobia. " The parts examined included the hemi- 
spheres, corpora striata, thalami optici, cornua ammonis, cerebellum, me- 
dulla oblongata, spinal cord, the sympathetic and vertebral ganglia. The 

1 Med. Kecord, i. 22. ^ British Med. Jour. vol. ii. 1874. 

Centralblatt fiir Med. Wissen., No. 50, 1875. Abst. Phil. Med. Times, Feb. 5, 1876. 



HYDROPHOBIA. 451 

most marked changes were observed in the two latter, and Were as fol- 
lows : 1. The vessels were enlarged, choked with red blood-corpuscles ; 
occasionally, extravasated red corpuscles and round indifferent elements 
(probably white corpuscles) were found in the perivascular spaces. The 
walls of the vessels were here and there filled with hyaloid masses of 
various forms, which occasionally extended into the lumen of the vessels, 
and closed this as a thrombosis would. Not far from these masses collec- 
tions of white and red biood-corpuscles could be observed, the latter de- 
prived of color. They could be seen also in all stages of metamorphosis 
into hyaloid globules. 2. In the pericellular spaces of the nerve-cells 
could be observed collections of round indifferent elements, whose pene- 
tration, to the number of five to eight or even more, pressed out the pro- 
toplasm of the cells. This penetration of the elements spoken of was 
frequently sufficient to change the form of the nerve-cells, giving them 
at different times a sac-formed, bulged, or flatten ed-out appearance. Fur- 
ther, the nucleus was sometimes pushed towards the periphery of the cell 
and surrounded by many round elements. In other cases, only groups of 
round (indifferent) bodies could be observed in place of the nerve -cells. 
In isolated nerve-cells the changes described could also be observed." 

The body of Dr. Hadden's patient was examined by the deputy coro- 
ner and several physicians, among whom were Drs. Clymer, Hammond, 
Cross and myself The calvarium was removed, and great congestion of 
the meninges and brain was observed. The sinuses were much engorged, 
but there was very little effusion either upon the surface of the brain or 
in the ventricles. The lower surface of the .brain appeared to be slightly 
softened in patches, but there was nothing else to attract attention, ex- 
cept it might perhaps have been a great hardness of the pituitary body. 
The internal viscera were all hypersemic, but there was no other morbid 
apperances. The larynx and trachea were found to be very much in- 
jected, and the latter contained a quantity of frothy mucus. Dr. AVillis 
has found the blood of persons who have died from this disease to be very 
fluid and of a dark color. Dr. Shattuck and Fitz ^ have published the 
notes of an interesting case of hydrophobia treated unsuccessfully by 
them. An immense amount of curare was given, about four grains within 
six hours, without any of the physiological effects being produced, though 
the drug was of good quality. Dr. Fitz's subsequent examination is of 
so much interest and so full that I present such parts of it as relate to 
the change in the nervous tissues : 

" While exposing the spine the surrounding tissue seemed to contain 
less fluid than usual. No abnormal appearances were observed in the 
membranes of the spinal cord, or upon the surface of sections made across 
the latter at intervals of an inch throughout its length. 

The calvaria was readily separated from the dura mater, both the 
bone and the membrane presenting no unusual appearances. The lon- 
gitudinal sinus contained a soft gelatinous clot, only partially filling the 

1 Boston Medical and Surgical Journal, Aug. 28, 1878. 



452 CEREBRO-SPINAL DISEASES. 

cavity. The pia mater was occasionally spotted and streaked from 
fibrous thickening, and was unusually injected over the greater part of 
the convexity of the brain, the vessels being often varicose. The 
meshes contained a considerable excess of clear fluid, and the membrane 
was readily detached from the brain. On section of the brain no un- 
usual appearances were observed in the ventricles or cerebral substance 
beyond abundant puncta cruenta. 

The chief interest naturally centered in the possible condition of the 
nervous system, and the spinal cord, medulla oblongata, and portions 
of the cerebral convolutions were preserved in Miiller's fluid for the 
purpose of microscopical examination. Positive results were obtained 
from the medulla alone ; it should be stated, however, that the cord- 
was perfectly hardened, so that the sections obtained from it were 
comparatively useless. The changes found in the medulla were ob- 
served throughout its length, and were most commonly met with in the 
posterior portion, especially in the immediate vicinity of the floor of the 
fourth ventricle. The alterations were most extreme in that part corres- 
ponding with the calamus scriptorius. The appearance most frequently 
met with was infiltration of the adventitia of the veins with small, round 
cells, both large and small veins being afiected. So abundant was their 
distribution that upon longitudinal section the wall of the vessel seemed 
to be paved, as it were, with these cells. As a rule, the vessels thus 
modified were distended with blood, and it seemed probable that the ob- 
served changes were pathological, as the vessels in other parts of the 
medulla did not present such an appearance. The injection of the veins 
was so complete at times that their section was of a dark-brown color and 
quite opaque, the individual corpuscles being indistinct, and the condi- 
tion deserved to be spoken of as a thrombosis. It was evident from 
transverse sections that the different cells were not simply adherent to the 
inner surface of the vessel, but were actually within the wall, nor was 
there any evidence of an increase in the relative proportion of white to 
red blood-corpuscles. 

Another appearance often met with was that of haemorrhage. In 
general the extra vasated blood was found within the perivascular, particu- 
larly venous, spaces. The sharply-defined outline of the corpuscles and 
the absence of granules of blood-pigment indicated that the haemorrhages 
were recent. Transverse sections of the injected vessel, with its wall in 
filtrated with round cells, and a perivascular accumulation of red blood- 
corpuscles, were often met with. In none of the sections were ruptures of 
the vessel wall seen. At times the wall was somewhat collapsed, the contents 
correspondingly less, while around the vessel a considerable hsemorrhage- 
was apparent. The hoemorrhages were usually limited to the perivasc- 
ular space, the blood rarely having made its way betw^een the nerve fibres 
or into the gray matter. 

Finally, an appearance was sometimes met with which may be spoken 
of as a miliary abscess. Occasional minute agglomerations of indifler- 
ent cells were seen, but their relation was such as to suggest their prob- 



HYDROPHOBIA. 453 

able origin from sections through limited portions of the infiltrated ad- 
ventitia already referred to. In two instances, however, actual abscesses 
were found, — one wihin a convolution of the olivary nucleus, another in 
the immediate vicinity of a pigmented ganglion cell in the upper part 
of the medulla. The former was a larger, and it was found in a part 
where none of the cellular infiltration of the vessels already mentioned 
was observed. 

In brief, then, the alterations were a diflPuse cellular infiltration of the 
adventitia of the veins, venous injection and thrombosis, perivenous 
haemorrhages, and miliary abscesses." 

The question to be answered after all is, whether this afiTection is a pri- 
mary disorder of the nervous centres or whether it is the result of general 
blood-poisoning. I am inclined to accept the latter theory, as the array of 
facts is too meagre to permit any positive assertion as to its nervous ori- 
gin. Like other disorders, not essentially nervous, there is a period of in- 
oculation, or incubation, of invasion, and development. I think, then, 
that in this re&pect this disease, as well as tetanus, resembles closely some 
of the exanthemata. 

Diagnosis. — It is important to bear in mind the fact that a great 
many so-called cases of hydrophobia are not this disease at all, and that 
certain forms of hysteria bear to it a close resemblance. Fright may 
act so powerfully upon the nervous system that a train of symptoms may 
be produced very much like those of the genuine affection. A case of this 
kind occurred at Bellevue Hospital a year or two ago, in which the 
symptoms counterfeited those of the real disease in every respect, and the 
patient finally died. It was found that the individual had not only never 
been bitten, but that he actually died of fear, his imagination having been 
stimulated by the sensational articles in the newspapers. Dr. J. W. S. 
Arnold, of the University, who examined the brain and cord, was unable 
to find the slightest indication of any morbid change. The only other 
conditions from which we may be required to make a differential diagnosis 
are tetanus, Calabar bean, and picrotoxin poisoning. In the former there 
are many points of resemblance, and occasionally a dread of liquids and 
a difficulty in swallowing. In tetanus, however, the risus sardonicus 
is present, the spasms are tonic, and there is opisthotonos, and the mind 
is clear to the last. 

In poisoning by both agents, to which I have alluded, the rapidity of 
their action is conspicuous, and a dose of either would carry the patient 
off in a few hours, more or less. In picrotoxin and Calabar bean poi- 
soning, there are many of the symptoms of hydrophobia, such as clonic 
spasms, frothing, rise of tomperature ; but no dread of water, nor delirium. 

Epilepsy may resemble hydrophobia, but it is only when the attacks are 
numerous and closely connected that such a mistake could possibly occur. 

Marbaix^ "gives a case of epileptiform convulsions more or less resem- 
bling hydrophobia, in a man who had been bitten four days before by a 

1 Presse M^d. Beige, 1869, 237. 



454 CEREBRO-SPINAL DISEASES. 

cat ; they were accompanied! by delirium and hyper^esthesia of the optic 
nerve, a stray light thrown across his eyes causing a convulsive attack. 
The shortness of the incubation, the blueness of the face, without the 
'vultueuse' expression characteristic of hydrophobia, the delirium, and 
the melancholy, not exalted, condition, combined with a history of an 
epileptic attack a year before, prevented the case being looked upon as 
one of true hydrophobia." 

Prognosis. — In true hydrophobia it is very bad. I believe there 
never have been more than one or two genuine cures reported ; and if 
others have been claimed, it is probable that no rabies existed, but that 
the affection described was simply hysterical. The chance of inoculation 
seems to be a matter of interest, for of the reported cases in which indivi- 
duals have been bitten, it has been found that about two-thirds of them 
subsequently developed symptoms of rabies. 

Treatment. — We rarely see these patients until actual evidences of 
madness have appeared. If, however, we are fortunate enough to be 
called to the individual immediately after he has been bitten, we may 
either incise or cauterize the wound. It is well to ligate the limb as soon 
as possible, and then remove en masse the piece of the muscle which has 
been penetrated by the teeth of the rabid animal. Various writers re- 
commend the cupping-glass, which should be applied to the excised part 
till it abstracts several ounces of blood from the wound. A pencil of ni- 
trate of silver may be thrust into the punctures made by the teeth of the 
dog until they are well cauterized, and a strong solution (5ij~§j) should 
be applied afterwards by means of a piece of folded linen, which is to be 
covered by oil silk. 

I am convinced that no remedy can do good where the disease has al- 
ready appeared, except, perhaps, curare, which has been tried; and in 
one case, where it was prescribed by Dr. Austin Flint, Sr., it is said to 
have saved the patient's life. 

The case must be desperate, however, when this powerful substanca is 
resorted to, for its preparation is not always the same, and no two speci- 
mens are of the same strength. It has been injected hypodermically in 
doses of one grain. 

Offenberg^ reports the cure of a girl of eighteen. She received at first 
hypodermic injections of morphine and chloroform, but there was no im- 
provement in her condition. Seven hypodermic injections, aggregating 
three grains of curare, were afterwards given in the course of six hours. 
The muscular disturbance subsided at once, and there was ultimate reco- 
very. The convulsions were succeeded by paralysis, which gradually 
disappeared. 

Hot baths have been recommended, but I cannot find that they have 
ever cured a case of this kind. 

HYSTEKIA. 
Synonyms. — Hysteric (Fr.) Muttersucht (Ger.) Vapors. 
~^ ~ " 1 Wien. Med. Presse, 1876, No. 1. 



HYSTERIA. 455 

Definition. — It would be almost impossible to give a concise defini- 
tion of this most protean of nervous afiections, for it simulates a multitude 
of organic and functional diseases so perfectly, that the task of considering 
it in any systematic manner would be attended with great difficulty. The 
nervous system in this respect is like the " general utility " actor. It 
plays the most varied parts. Sometimes we are presented with a hemi- 
plegia or paraplegia, and at others with contractures which seem to be the 
result of organic disease, so permanent and intractable do they appear. 
Convulsions, ansesthesia, urinary and other troubles of a more or less 
grave character, swell the list, until we are almost inclined to look upon 
it as a " disease of the Devil," and cease to wonder at the credulity 
and superstition of those who believe in demoniac possession and witch- 
craft. Confining ourselves as closely to the subject as possible, we con- 
clude that hysteria is a disease of an emotional character chiefly among 
women, in which the symptoms are rarely the same in any two instances, 
but among a large number of cases there can be noticed a certain simi- 
larity. 

Symptoms. — These symptoms may be grouped as sensorial, motorial, 
and mscercd. Sensorial symptoms are of three kinds ; hypereesthetic, 
ansesthetic, and mental. Hypersesthesia, though much more common 
than anaesthesia, is not so marked. Large areas of hypersesthesia may be 
detected by careful exanaination, though the patient usually saves this 
trouble, for she calls attention to the weight of her clothes, the pressure of 
some fold of her underwear, or the contact ^of some very light substance 
which is pronounced unbearable. The external organs of generation are 
extremely sensitive, and the slightest touch of the finger or speculum pro- 
duces a spasm and great agony. Coition is impossible, and one patient 
called my attention to a horrible shooting pain which occurred whenever 
her husband approached her. Hypersesthesia about the nipples, at the 
end of the coccyx, and in other parts of the body, is alluded to by vari- 
ous writers. Charcot has directed attention to the prominence of these ; 
and Briquet has described fixed pains of the abdomen which he called 
Gcelalgice, and of 450 cases he found 200 presenting this symptom. They 
were hypogastric and iliac, but more commonly the latter. These have 
sometimes been mistaken for the pain of peritonitis ; there is, however, 
no tenderness, but simply superficial elevation of sensibility. The pa- 
tient often calls attention to vague pains in diflferent parts of the body, of 
a transitory, and sometimes permanent character. She complains of 
strong light and loud noises, and insists upon perfect quiet, although she 
will herself talk and cry in a very noisy manner. All of her pains are 
increased when her attention is concentrated upon them, but when her 
mind is diverted she will bear very rough treatment without complaint, 

Neuralgic pain, a familiar variety being tne clavus hystericus, is a com- 
mon form of complaint. Various local pains are also experienced, and 
these, among others, include alterations in sensibility which simulate lum- 
bago ; indeed, a very constant hysterical complaint is backache, which 
the patient generally attributes to the kidneys. A most interesting form 



456 CEREBRO-SPINAL DISBASES. 

of hysterical dyssesthesia has received mention from Skey, Paget, and 
others, and is very often mistaken for rheumatism. The joints are neither 
swollen nor red, however. M. Meyer,^ in an interesting article upon 
the subject, gives the leading points in diagnosis as follows : " 1. The neu- 
ralgia is of a diurnal form entirely. 2. Light pressure of joints produces 
pain, but comparatively violent handling is not at all painful. 3. The 
temperature of the affected joint undergoes variations. 4. There is no 
loss of substance of the muscles of an unsound limb. 5. The cure is 
usually spontaneous." The mental disturbances are of the most interest- 
ing character, whether expressed by transient emotional excitement or 
apparent prolonged unconsciousness. Examples of the lighter grades are 
too familiar to need description, and it is only necessary to allude to the 
outbursts of immoderate laughter or crying which occur when there is no 
reason for either emotional elation or depression. Such individuals may 
indulge in laughter at church or at a funeral, and, while perfectly aware 
of the impropriety of their conduct, will be utterly unable to restrain 
themselves. Illusions, hallucinations, and even delusions are evidences 
of a very irritable condition of the nervous centres, as are ecstasy and 
mental excitement of various kinds, such as belief in impending calamity 
or death. The involuntary use of foul words and gestures, and a remarka- 
ble eccentricity of behavior, are additional suggestions of a disordered 
state of the emotions. Wynter,^ in his excellent little book, thus alludes 
to a condition which, after all, is but a manifestation of hysteria. 

" There is a terrible stage of consciousness in which, unknown to any 
other human being, an individual keeps up as it were a terrible hand-to- 
hand conflict with herself when she is prompted by an inward voice to use 
disgusting words, which, in her sane moments, she loathes and abhors. 
These voices will sometimes suggest ideas which are diametrically opposed 
to the sober dictates of her conscience. In such conditions of mind, 
prayers are turned into curses, and the chastest into the most libidinous 
thoughts." ^ The will is quite weak, while the emotions, far from being 
held in abeyance to the extent which they are in health, respond to trivial 
ideational impressions. The hysterical person firmly believes herself to 
be the subject of various disorders of a greater or less serious character ; 
is hopeless ; believes in a speedy fatal termination of her imaginary 
trouble ; and can only be convinced of her mistake by fear of the reme- 
dy suggested, or by some strong appeal to her appetite or comfort. While 
in a state which may sometimes appal the observer, the patient declares 
her inability to walk. If, however, some powerful excitement be pro- 
duced, such as an alarm of fire, she quickly recovers the use of her legs. 
I have recently seen a most interesting case of hysterical torticollis, in 

1 Berliner Klin. Woch., 1874, No. 26. ^ Borderland of Insanity, p. 3. 

3 Hysterical girls and women occasionally evince a depraved appetite, eating all 
sorts of extraordinary things. The school-girl habit of eating slate-pencils is an ex- 
ample of this. I have personally observed this evidence of hysteria on many occa- 
sions. A young lady recently under treatment ate enormous quantities of nutmegs- 
The morbid appetite of pregnancy is probably an hysterical disorder. 



HYSTERIA. 457 

whicli the patient refused to turn or raise her head. I quietly seated my- 
self at her other side, and engaged her attention so fully that after a 
while she turned her head and talked for some time ; and it was only 
when I referred to the subject of her troubles that she quickly resumed 
her original position, and I could not persuade her to change it. She may 
at times believe that she is deaf or dumb, and remain in such an uncom- 
fortable condition for years, punishing not only herself, but making all 
about her uncomfortable. 

One of the most striking mental characteristics of the hysterical woman is 
her utter want of confidence in herself. She relies upon all those about her, 
and goes to her physician at all hours and with no object in view except 
the need for sympathy. She often has an impending dread of some ca- 
lamity, and requires constant reassurance. If the physician could give 
her the belief that she could control her own emotions and conquer, much 
might be done. She even may know how unsubstantial are her symptoms 
— her paralysis, for instance, but she says " I cannot help it ; I have every 
desire to move my leg, or my arm, but I know that I cannot." 

Hysterical anaesthesia has received a great deal of attention of late 
years from the French observers, especially from Charcot, as well 
as Piorry and Gendrin. Briquet^ has found that this condition oc- 
curs more frequently on the left than upon the right side. It may be 
superficial or deep, even aflfecting the muscles and bones. Reynolds has 
found it limited often to the back of the hand or foot, or about the mouth 
and nose. The vaginal canal and the lining mucous membrane of the 
mouth are also places where there may be loss of sensation. Hysterical 
hemiansesthesia does not diifer from that due to cerebral hemorrhage so 
far as the symptomatology is concerned. The same regions are affected 
and the same complicated amblyopia takes place. Taste and smell 
are unilaterally involved. Hysterical anaesthesia not rarely follows, 
or comes on during a convulsive attack, and lasts for a variable time. It 
may subside in a few hours, or continue for months at a time. During its 
existence the most violent stimuli will fail to restore sensibility ; and I 
have often used powerful counter-irritants, electricity, or even the hot 
iron, without any response whatever. The loss of sensation may extend 
more deeply, so that the underlying muscles may be utterly without sen- 
sation. This peculiarity probably explains the insusceptibility to pain 
spoken of by Carre de Montegeron. The Jansenists or Convulsionnaires 
" became so wrought up by religious excitement that they fell, twenty or 
more- at a time, into violent convu^ions, and demanded to be beaten with 
huge iron-shod clubs, in order to be relieved of an unbearable pressure 
upon the abdomen. One of the brothers Marion felt nothing of the 
thrusts made by a sharp-pointed knife against his abdomen." 

Not only may there be analgesia, but loss of appreciation of heat or 
cold, and the surface may become blanched and white, and the skin even 
bloodless. Brown-Sequard has demonstrated the absence of blood ; a fact 

^ Traite Clinique et Therapentique de I'Hysterie, Pari^, 1859. 



458 CEREBRO-SPINAL DISEASES. 

which has an historical interest ia connection with the tests of the early- 
religious enthusiasts. Charcot alludes to the epidemic of St. Medard, 
when the cut of a sword failed to produce any flow of blood. The tem- 
perature of the anaesthetic spot is sometimes lowered two or three degrees, 
and varies in different regions. There may be anaesthesia of the mucous 
membranes of the mouth, the pharynx, and larynx ; or the organs of 
special sense may be implicated, and a resulting amaurosis, amblyopia, or 
deafness ensue. In a paper upon " Hysterical Affections of the Eye," by 
Dr. Geo. C. Harlan,^ of Philadelphia, attention is directed to retinal an- 
aesthesia and various hysterical disorders of an interesting character. 

" Almost any derangement of vision may be counterfeited. A little girl 
of eight years complained that every object that she looked at seemed 
covered with diagonal white lines, the direction of which she indicated 
with her finger. As the ophthalmoscope revealed a normal fundus, a 
favorable prognosis was given. This was made more positive the next 
day, when the white lines changed to blue, and was justified by the early 
disappearance of the difficulty. 

•' In the second class of cases we have more or less retinal anaesthesia, 
with anomalous and variable symptoms, changing, perhaps, at each ex- 
amination. 

" In the third class of cases the parts affected have been the retina, the 
muscle of accommodation, the external muscles of the eyeball, and the 
elevator of the upper eyelid. 

" It is not very uncommon to meet with patients who have apparently 
perfect eyes and full acuity of vision, but who say that the test letters be- 
come blurred and unrecognizable after they have looked at them for a few 
seconds. That this is due to an exhaustion of the sensibility of the retina 
which disables it from the sustained performance of its function, and not 
to an irregular action of the accommodation, is shown by the fact that it 
persists when the eye is fully under the effects of atropia. 

As to color blindness in hysterical women, I think its importance has 
been exaggerated, and I have very rarely met with even the slightest 
affection of the color-sense, unless the hysteria has existed in connection 
with cerebral disease and hemi-anassthesia. 

Taste and smell are sometimes impaired, so that there is a greater or 
less extensive loss or a perversion, the patient declaring that natural odors 
are reversed, or that articles of food are tasteless. 

The Moiorial symptoms are numerous, and maybe either of asthenic or 
asthenic character. The more simple include spasms, violent gesticulations, 
and contractures : the more obstinate, paralysis of either a hemiplegic, 
or paraplegic, or even a local form, and chorea and convulsions, as well as 
various kinds of muscular incoordination. The individual may assume 
the most painful positions, the limbs being rigidly flexed or extended, and 
the face distorted by grimaces of the most absurd description. Sometimes 
there is torticollis, or spasm of some small group of muscles, or the muscular 

1 Phil. Med. and Surg. Eep., August 12, 1876. 



HYSTERIA. 459 

rigidity may even amount to opisthotonos, pleurothotonos, or emprostlio- 
tonos, and these forms of trouble are much more marked in conditions of 
hystero-epilepsy and hystero-catalepsy. The dependence of these motorial 
phenomena upon reflex excitement is their marked feature, slight peri- 
pheral irritations, uterine trouble, or sexual excitement of any kind, often 
being the origin of the affection. 

The pharynx, larynx, and not rarely the stomach are implicated, so 
that difficulty of swallowing, loss of speech, and vomiting are resulting 
phenomena. Hysterical attacks of a convulsive character are met with 
sometimes, when the patient is apparently unconscious, but is in reality 
not at all so. There is slow respiration, which is scarcely perceptible, and 
small weak pulse. The legs and arms may be wildly thrown about, or 
rigidly extended, and there may be opisthotonos, while the skin is livid, 
and may be bathed in perspiration. A lighter grade of attack is frequently 
seen, in which the patient, after a period of excitement, screams, and falls 
to the floor (being very careful not to hurt herself) ; her muscles become 
contracted ; she breathes heavily, froths at the mouth, talks incoherently, 
and berates those about her. She may cry, and in doing so sobs violently, 
sometimes catching her breath in an alarming manner, frightening her 
attendants and attracting sympathy. If left to herself and not noticed, 
she may fall asleep or gradually recover. The patient looks about the 
room during the attack, and is undoubtedly conscious of what transpires. 
One significant mark of hysteria, previously alluded to, is that, however 
much the patient throws herself about, she is always careful not to do her- 
self injury. Pomme^ was among the first to describe hysterical contrac- 
tures, and later Gorget related a case of hysterical flexion of the thigh 
upon the pelvis which was supposed to be due to coxalgia. In hemiplegic 
contractures the upper limb may be drawn in to the trunk, the forearm 
is flexed at a right angle, the thumb is bent so that the point is buried in 
the palm of the hand, and it is covered by the other fingers. 

According to Strauss,^ extension of the upper limbs is quite rare. The 
lower limb is extended, so that the foot presents the appearance of talipes 
equinus, the toes having a claw-like appearance. The thigh is extended 
on the pelvis, and the whole limb is adducted. 

Hysterical contractures of a permanent character may affect the body, 
either laterally or below the waist, or but one member may be involved. 
Charcot^ relates a case in which the left leg was firmly extended. The 
foot presented the deformity of talipes varus, and the limb was very rigid, 
so that, by lifting it, the body could be moved without bending the knee . 
The contracture could be overcome by chloroform, but returned when its 
effects had disappeared. In this case the limb was agitated by a tremor, 
or " tremulation convulsive," as this author calls the movement. These 
hysterical contractures often last for years, and are cured spontaneonsly. 
Skey *. relates a case which is quite interesting. 

^ Traite des Affections Vaporeuses. ^ Op. cit., p. 307. 

^ Des Contractures, Paris, 1S75. * Hysteria, etc, London, 1866. 



460 CEREBRO-SPINAL DISEASES. 

" In the year 1864 a young lady of 16 years of age was placed under 
my care under the following circumstances: For eight months prior to 
her visit to me, she had been suffering from inversion of the left foot, 
which was so twisted as to bring the point of the foot to the opposite 
ankle ; in fact, at nearly a right angle with the foot of the opposite side. 
Her family consulted a surgeon of much experience in the treatment of 
distortion, and of orthopaedic notoriety. The case was considered as an 
example of an ordinary distortion, and the foot was placed in a very ela- 
borately made foot-splint, by the force of which it was made to approach 
a parallel relation to the opposite side ; but it was an approach only, for 
no mechanism could retain it in a perfect position, the toes yet to some 
degree pointing inwards. A month elapsed, and the disease continued 
unchanged. A second orthopsedic authority was then consulted in con- 
junction with the first, and as no new light was thrown on the disease by 
the combined opinions of the two, the same principle of treatment was 
recommended to be continued, and the mechanism was yet somewhat 
more elaborated, and thus the eighth month of the young lady's life passed 
away, during which no constitutional treatment was resorted to, and loss 
of exercise, for she walked, it was almost unnecessary to say, with great 
difficulty." 

Skey examined the foot, and arrived at the conclusion that the inver- 
sion was too great to be due to the muscles alone, and discovered that 
those of the whole limb were involved ; that the disease had appeared 
suddenly in a girl of 15 years, who was otherwise well and strong, and in 
whom there was no indication of acute local disease. 

The apparatus was removed ; a hearty diet, with tonics, was ordered ; 
she was told to walk ; and at the end of six m'onths was invited to a ball, 
her foot being still deformed. She accepted an invitation to dance, and 
remained standing throughout the entire evening. She had been sud- 
denly cured. 

Hemiplegia and paraplegia of an hysterical character are sometimes 
met with, as well as local paralysis, but the face is rarely affected in 
hysterical hemiparesis, and the tongue never so. 

The walk is quite different from that of organic hemiplegia, and 
the foot is simply dragged along . and not swung, and there is an 
absence of that helplessness which is so characteristic of the seri- 
ous trouble. Electric sensibility and contractility are not usually 
affected, though the former may be occasionally impaired. The cure is 
spontaneous, and there is never atrophy or any of the peculiar tissue 
changes of neuritis which generally follow hemiplegia from cerebral dis- 
eases. Paraplegia of the hysterical variety is rarely attended by any 
urinaiy or rectal trouble, and never by incontinence, and the muscles are 
well nourished and respond to electric stimulation. Some voluntary 
motion is possible in the recumbent position, and it is only when the 
patient walks that she shows her loss of power. Reynolds states that a 
peculiarity of the disease, which is familiar to all, is the fact that no 
amount of help can keep the patient from staggering or falling ; she may 
be supported by strong arms, but she sinks to the ground, not, however, 
falling entirely, but regaining her position by a voluntary effort. 

The patellar tendon-reflex is usually increased upon the paralyzed 



HYSTERIA. 461 

sid3 ill hysterical hemiplegia. I have never found it to be diminished, but 
care should be taken to define the line between the paralysis, due to 
myelitis, with hysterical symptoms, and the hysteria, in which there is 
paralysis. I have referred to the former cases in a previous article. 

The visceral troubles are a host in themselves. ISTot only may the 
patient complain of unbearable pains situated in the liver, stomach, and 
other organs, but there may be urinary affections of considerable impor- 
tance. Two varieties of hysterical urinary derangement are spoken of 
by Charcot, one being ischuria, and the other a complete suppression, 
which he has called oligurie. In both cases the urinary passages are per- 
fectly normal ; in the first there is simple retention of urine in the 
bladder ; and for a long time (amounting even to months or years) it will 
be found necessary to use a catheter. 

Laycock^ has called attention to this state of affairs, which lasts some- 
times twenty-four or thirty-six hours, during the menstrual epoch. 
Charcot has found the condition to last even longer — sometimes for seve- 
ral days. This suppression of urine is occasionally accompanied by 
vomiting, and the presence of urea has actually been discovered in the 
vomited substances. This has been explained by the experiment of 
Brown -Sequard, who found that after certain forms of mutilation car- 
bonate of ammonia or free urea was found in the intestines of animals, 
which settled the fact that there was a " supplementary elimination." 
This same condition of affairs is not unusual in renal disease, and the 
odor of the breath and sweat is decidedly uriniferous. Vomiting of fecal 
matter is a rare symptom. There is in the majority of cases a decided 
increase in the amount of urine voided. It is of a very light color, quite 
limpid, and of low specific gravity, and is sometimes discharged during 
the convulsive seizure. Digestive disturbances, accompanied by eructa- 
tions of wind, borborygmi, epigastric pain, and loss of appetite, are pre- 
sent in most cases. 

Abstinence from food and continued unconsciousness need hardly be 
alluded to in this chapter. Cases of this kind derive sensational impor- 
tance from newspaper description, and from their very hysterical nature 
suggest fraud and deception. The case of Louise Lateau, as well as 
others, has been cleverly investigated, and is doubtless familiar to my 
readers. The history of this class of cases furnishes us with many exam- 
ples, some of which are quite ancient. 

Senneratus^ writes of three individuals who fasted almost two years, 
and " yet) though lean, were in good health." 

Upon the authority of Schenck/ we are informed that "Katherine 
Binder, a native of the upper Palatinate in Germany, was said to receive 
no other nourishment than air for more than nine vears. John Caffimer, 
in the year of our Lord 1585, commanded her to be watched by a Minis- 
ter of State, Ecclesiastic and two Licentiates in Physic, but they could 

^ Treatise on the Nervous Diseases of Women, London, 1340, p. 229. 
2 Prax Med., p. 212. ^ Obs. 1. 3, p. 306. 



462 CEREBRO-SPINAL DISEASES. 

make no discovery of her being an impostor, and therefore reported- it to 
be miraculous." 

A symptom which I am inclined to think very common, but which is 
not generally considered so, is the globus hystericus. The patient calls at- 
tention to a " lump which rises in her throat." It is probably nothing 
more than a spasmodic contraction of the muscles of the pharynx or ceso - 
phagus, or in other cases a morbid, sensory disturbance. It " rises " from 
the epigastrium, and is attended by dyspnoea and difficulty in deglutition. 
In some cases obstinate vomiting, which is readily excited by such slight 
agencies as a hand laid upoa the surface of the body, or the administra- 
tion of a very small amount of food, is a formidable symptom, and unless 
corrected the patient may become speedily exhausted. In one case which 
I saw at the request of Dr. Austin Flint, this condition had lasted for seve- 
ral years, and was not relieved by any medication, but was for a time 
stopped by pressure made over the left ovary. 

The disease among males is of interest because of its rarity. A case 
presented by Bonnemaison,^ of Toulouse, may be cited : — 

The patient was a man aged 72. The brother of the patient was a 
hypochondriac; and his mother, who died at the age of 81, suffered from 
various forms of nervous disturbance, analogous to those of her hysterical 
son, after reaching her 76th year. The attacks in the case of Dr. Bonne- 
maison's patient came on three or four times in the twenty-four hours ; 
ushered in, when occurring during the night, by nightmare ; when in the 
day, by various sensations, and usually by pain in the epigastric region. 
An aura proceeding from this point traveled along the sternum to the 
throat, and thence to the mouth and tongue, and other regions of the 
body, the muscles of the parts affected by this sensation being thrown into 
violent, rapid, and unaccountable convulsive action. The patient uttered 
strange cries and yells, or repeated the same words over and over again 
with extreme rapidity. At times the tongue would be smacked violently 
against the roof of the mouth, the cheeks spasmodically puffed out with 
the action of blowing or whistling, and the jaws snapped violently toge- 
ther, without, however, biting the tongue. The arms were moved rhythmi- 
cally together with the action of flying, or drumming, or playing the 
piano. Sometimes the lower limbs shook violently, or executed the 
movements of dancing. The attacks bore a strong resemblance to those 
of the " convulsionnaires " of St. Medard, or the rhythmic chorea of the 
epidemics of Louviers, Toulouse, and Morziac. The disturbance of the 
voluntary muscles might be accompanied by spasm of the involuntary 
mu-cles also, or the latter might form the chief phenomena of the parox- 
ysm, consisting in hiccup, eructations, sighs, and borborygmi. During 
the whole of the attack the hypergesthesia of the skin was excessive, 
especially at the forehead, epigastric region, and sternum ; there was no 
loss of consciousness. The attack ended either wi:^h a copious flow of 
limpid urine, or a discharge of tears. There was never any pain or 
sensation referable to the generative organs, nor anything whatever in 
the history of the symptoms indicative of their implication in any way 
whatever. The same absence of any pathological condition of the organs 

Abst. in Med. News, Oct. 1875. 



HYSTERIA. 463 

of generation has been observed in cases of male hysteria observed by 
others. 

Children are not exempt from hysterical troubles, and much of the 
perversity of young children will often be found to be of this character. 
If this fact was recognized, a great deal of the suffering in after life 
might be prevented. 

Many of Briquet's cases began before the twelfth year, and it will ba 
found that even before puberty the tendency to this trouble may be often 
recognized. 

Dr. Jacobi,^ whose careful investigations of the nervous diseases of young 
children have furnished us with striking facts, looks upon hysteria as an 
extremely common trouble among young children, connected often with 
masturbation even in infants of two or three years. Jacobi refers to the 
tables of Briquet, Amann, and others, to show that hysteria is found 
frequently before adolescence. Of Amann's cases, 16 of 268 cases were 
between 8 and 10 years; of those of Althaus — 820 —seventy-one were be- 
fore the tenth year. Landouzy collected 300 cases, 48 of whom were 
between the tenth and fifteenth years. 

Causes. — Hysteria is most decidedly an affection of women, and is 
connected in many instances with some sexual or uterine derangement. 
Among men hysteria is far le«s rare, I think, than it is supposed to be, 
but with them the hysterical trouble is of a lighter grade, and it is un- 
usual for examples either of anaesthesia, convulsions, or contractures to be 
witnessed. As a rule, the hysterical man possesses a smooth face, slen- 
der figure, soft falsetto voice, large thyroid ~ cartilages, small hands, and 
tapering fingers, and sometimes large mammae. His genital organs are 
poorly developed, and his manners are mincing and effeminate. Hysteri- 
cal phenomena are, however, not uncommonly presented by stalwart men. 
Among women this approach to the appearance and behavior of the other 
sex is inconsistent with the development of hysteria. Women with bushy 
eyebrows, coarse hair, perhaps a slight moustache, angular build, narrow 
hips, and coarse voices are seldom hysterical. They are "strong-minded," 
rarely emotional, and inclined to look upon the hysterical trouble of their 
weak sisters with something like contempt. 

Reynolds aptly says : " Some women are as little likely to become 
hysterical as some men are to fall pregnant." It might be added : and 
as their chances to conceive are diminished. Hysteria is of much more 
common appearance among spinsters and single women, and is far from 
being rare among old maids who marry late in life. A case of this kind 
fell under my observation some years ago. An examination revealed an 
undeveloped uterus ; and from the nuptial night dated a series of ner- 
vous symptoms of a grave hysterical character. The uterine irritability 
which is connected with the pregnant state between the ages of thirty and 

^ On Masturbation and Hysteria in Young Children, by A. Jacobi. Am, Jour, of 
Obstetrics, etc., vols. viii. and ix., 1876. 



464 CEREBRO-SPINAL DISEASES. 

forty is apt to produce a profound impression upon the nervous system. 
Among married women with impotent mates, or among those who 
have, on the other hand, suffered through the lust, inconsideration, and 
brutality of husbands of another kind, the disease is not uncommon. The 
puerperal state, lactation, and the cessation of the catamenia favor its 
development. 

I have lately treated a number of cases of a class which I am sure is 
familiar to most medical men, especially to those who devote the greater 
part of their time to the study of nervous disease. I allude to certain 
ill-defined hysterical conditions that are connected with or follow the pu- 
erperal state. These cases do not come under the head of puerperal 
mania, which is a common and well-recognized form of insanity, but are 
difficult of description and classification, because of their irregularity. 
The patients I have seen have all been ursemic at some time during preg- 
nancy, not to the extent which is accompanied by convulsions or other 
grave symptoms, but the blood-poisoning was much more extensive than 
it usually is. Barker thinks that albuminuria is not the cause of puerpe- 
ral mania, but, when found, is merely a coincidence. In the cases 1 allude 
to it was always present, and seemed to be the cause. I have seen the 
same symptoms expressed, though in a less marked degree, in patients 
who were suffering from chronic nephritis, and where the puerperal state 
had nothing to do with the history.^ 

In the spring of 1875 Mrs. C came to my office with her husband. I 
found her to be an amiable, well-educated woman of thirty-two years of 
age ; her manner was cheery and agreeable, and there was no evidence of 
mental trouble. Three months before this she had been delivered of a 
child at full term, which was born dead. A week after her milk " dried 
up." The last months of her pregnancy were attended by evidences of 
ursemia, marked anasarca, clouded urine excreted in small quantity, but 
no convulsions or mania. Mrs. C.'s previous history was uneventful. 
There was absolutely no hereditary predisposition to insanity, and her 
mind was perfectly clear during pregnancy. 

She was anaemic, and complained of dizziness, palpitation, gastric dis- 
turbance, vertical headache, loss of memory, ringing in the ears, etc. She 
passed her urine at the time of her visit in normal amounts, and it did not 
contain albumen. Her complexion was pale, and her pupils were dilated. 
A very slight blueness of the skin was apparent, but was confined to the 
hands. The lips had not lost their lines of expression, which is generally 
the case in melancholia, and they were not swollen. She was inclined to 
sleep. Considering that the symptoms indicated '• cerebral anaemia," I 
began with iron, phosphorus, and other remedies of the same kind. 

Two days after this visit she again appeared at my office, looking much 
agitated, and saying that she had come for " protection from herself." 
She had been tempted to get up from her bed and cut her throat with her 
husband's razors. She was perfectly cognizant of her condition, and was 
aware of the fearful nature of the act she was tempted to perform. After 
a talk of half an hour, she left me, feeling settled, and without the desire. 

•^ Bost(jn Med. and Surg. Journ., June 15, 1876. 



HYSTERIA. 465 

On another occasion she came to see me, as "she had the feeling again." 
She had taken her sister's baby in her lap, and while it was there she 
"suddenly felt like throwing it on the floor ' with all her force. At 
another time she was prompted to run the blade of a pair of scissors into 
the fontanelle. These impulses would recur every week or so, when she 
always came to see me, and would sit a few minutes, talk upon other sub- 
jects, and rise to go, saying : " Now, doctor, the feeling has passed off" 
Not at this time, nor at any other, were there delusions of any kind. 
Under treatment she improved in general health, and her nervous symp- 
toms disappeared. 

Her last morbid impulse occurred during the fourth month after treat- 
ment. One evening, with her husband and brother, she went upon the 
house-top to see a fire. While there the old feeling returned, and she 
would have thrown herself from the roof, had she not been prevented. 
This was the last and most serious expression of the disease. Since that 
time she has not had a return, and says she is perfectly well. 

A second case I lately saw was attended by slight though perfectly de- 
fined mental changes. The patient was a young married woman of 
twenty-four years. For some time before parturition and during her 
pregnancy there was kidney trouble. Before her labor she was a loving 
and devoted wife, but shortly after lost all of her amiability, and treated 
her husband and mother with marked coolness, and sometimes with de- 
cided rudeness. A month after delivery she took a deep interest in re- 
ligious matters, and carried the observance of her religious duties to such 
a pass as to be disagreeable to all about her. She did eccentric things, 
such as getting up at night, going down to the piano in the drawing-room, 
and singing hymns. When reminded of the unseasonableness of the hour, 
she would return to her bed, first shutting the hymn-book in a mechanical 
manner. 

I saw her in this condition, and found a state closely bordering on mel- 
ancholia, though there was no mental depression, no anxious facies, no 
sighing, no hopelessness. A persistent use of agents which would restore 
the action of the kidneys, combined with fresh air and a well-regulated 
diet, did her much good. After a few weeks the patient slept well, and 
the mental irritability gradually disappeared. 

In both of these cases there were symptoms which were not those of 
insanity. In Case I. the patient was able to reason, and had full con- 
sciousness of her infirmity ; so that she had the power to seek the society 
of others when she felt the impulse. There was the absence of all physi- 
cal signs of insanity, except the coloration of the skin. In the second 
case, the short duration of the mental trouble, and its subsidence with 
improvement of the kidney difficulty, proved it to be a functional de- 
rangement. 

As regards age, pronounced hysteria rarely begins before the twelfth 
year; it generally takes its origin at the time of puberty, and from this pe- 
riod may continue through life. It not rarely begins after marriage, or 
sometimes not until after the menopause, but this is exceptional. In males 
it begins in middle life, though I have seen the afiection among boys. Hys- 
teria is not necessarily a disease of the well-to-do, though indolent habits and 
luxurious living favor its development ; but it frequently appears among 
30 



466 CEREBRO-SPINAL DISEASES. 

overworked shop-girls who are compelled to stand for many hours during 
the day. The follies of fashionable life have much to do with the pro- 
duction of a morbid performance of functions of the nervous system. 
Continued rounds of dissipation, parties and balls which do away with 
sleep, together with excitement and late suppers, days of idleness spent in 
reading sensational novels and eating improper food, or tippling liqueurs, 
especially favor the development of this morbid state. This mode of life, 
when kept up for some time, especially when the menstrual periods are 
disregarded, brings about a condition of erethism which expresses itself 
in the symptoms I have named. Dysmenorrhoea may be attended by 
attacks, and so may menorrhagia, but many cases occur even when there 
is no disturbance of menstrual function. Abnormalities of the posi- 
tion of the uterus, and excessive sexual excitement, whether from mas- 
turbation or coition, have decided etiological bearing, while warm 
weather favors the development of attacks. Mental worry, emotional 
excitement, an attack of illness, and a number of influences of the same 
kind all act as exciting causes. 

Morbid Anatomy and Pathology. — Accidental lesions are some- 
times found, but so irregular is their character that they are valueless as 
indications. 

As to the pathology of the affection, very little can be said in addition 
to what has already been stated in speaking of the symptoms. Hysteria 
may be said to be a very near relation to insanity, and one writer even con- 
siders it a form of insanity; but I should be loath to believe that so many 
people are actually insane. Hysteria is rather a mental inco-ordination. 
Emotional exaltation, connected with liveliness of ideation and with 
feeble volition, and a, paralysis of judgment, may be said to be the mental 
condition of an hysterical patient. The balance is lost ; and when the 
emotional side has full play, all the reflex and sensational functions are 
active and unchecked, while it is only with difficulty that the governing 
side to which belong volitional and intellectual control is made to counter- 
act the other. This is only brought about by the most powerful agencies, 
and sometimes fhese are inefficient. If the reader will consult an article 
by Lauder Brunton,^ in one of the West Riding Reports, he will find 
some excellent diagrams which illustrate the mechanism of the nervous 
centres in the physiology of inhibition. 

I have slightly modified the chart of this author by introducing another 
centre. Let Fig. 60 represent the arrangement of nerve centres concerned 
in the performance of the functions of the cerebro-spinal system. I. indi- 
cates the centre of ideation, E. an emotional centre, W. a will centre, M. 
a motor centre innervating ; m (a muscle), y (a vessel), and g (a gland). 
S. is a sensory centre, and P. the origin of an external impression. The 
connecting lines are efferent and afferent nerves. It will be seen that I is 
in centrifugal communication with W, with M, S, and with E. So that 
ideas which are evolved without external stimulus may find motor expres- 

^ West Riding Lunatic Asylum Reports, vol. iv. p. 179. 



HYSTERIA. 



467 



sion either in a voluntary or involuntary manner ; may affect the emo- 
tional centre, or may be stimulated by impressions received either from 
that centre or from S. External impressions may be transmitted from P 
either to S, to E, or to M ; in one case being perceived and transmitted 
to a higher centre, or being converted into a reflex action. E is affected 
by S and by I, and in turn influences M and I, and to a slight degree W ; 
or on the other hand may be controlled by "W. In the normal state we 
may roughly suppose the proportions of these areas to be represented in 
the right-hand diagram. In the hysterical state their relative (left-hand 
diagram) size is greatly altered ; E gains in size, and W is very much 
diminished. The relative size of the communicating tracts also under- 
goes modification. Though this explanation is decidedly rough and super- 
ficial, I trust it will give the reader a better idea of the pathology of this 
affection than would any extended written description. 



Fig. 60. 








X 


I 










^M 


\ 




w 


-H E 


\ 


B 


vl 


/ ' 


.\ 


\ 


n^ 


■ 1 

M 






s 


m 


y 


Nv^ / 


/ 



The Pathology of Hys t eria. 

Diagnosis. — As hysteria may counterfeit nearly every known symptom, 
it will be seen that the task of making a diagnosis is not always an easy 
matter. If, however, we consider that the symptoms are generally presented 
in a group, which is decidedly irregular and its elements inharmonious, and 
that the patient is on the alert in regard to all that goes on about her; 
that she has a fear of severe treatment ; that the use of chloroform will 
certainly overcome the contractures; and that the cure is generally sudden, 
there is not much chance for mistake. Besides, there is never any evidence 
of gross organic change, the muscles only losing their fulness from inaction. 
Jannet^ says that the difference between hysteria and epilepsy, with 
which it is often confounded, can be detected by the thermometer, there 
being no change in the former trouble. 



^ De r hyst^rie chez 1' homme, Th^sede Paris, 1880. 



468 CEREBRO-SPINAL DISEASES. 

Prognosis. — If the iadividaal has suffered for a great length of time, 
and especially if there be confirmed uterine or ovarian disease, the chances of 
entire recovery will be extremely bad. The disease is not only discouraging 
in the way of treatment, bat annoying to the friends, and far more disa- 
greeable to the physician, who receives very little for his pains but abuse 
and want of appreciation. Some cases may be easily cured, and these 
are among young people. Much, however, depends upon treatment. Dr. 
Mitchell has known of three deaths from hysteria, and all three were 
abrupt, and one was due to acute congestion of the kidneys. In two 
cases that have fallen under my notice, death has taken place in an en- 
tirely unexpected way. In one patient there was intense cerebral oedema, 
and the other, seen by Dr. Ball at my request, rapidly developed 
uraemic symptoms and died comatose, her death being preceded a few 
hours by hemiplegia. 

Treatment. — The history of the treatment of hysteria is curious in 
the extreme. Going back to the middle ages we find numerous examples 
of miraculous cures, which were undoubtedly of an hysterical character. 
Scheie de Vere, in his little work entitled " Modern Magic," thus speaks 
of a favorite mode of treatment which has been followed by the Zouave 
Jacob and many others in modern times : — 

" The imposition of hands for the purpose of performing miraculous 
cures has been practised from time immemorial ; Chaldees and Brahmins 
alike using it in cases of malignant disease. The kings of England and 
of France, and even the counts of Hapsburg in Germany, have been 
reputed to be able to cure goitres by the touch of their hands. The idea 
seems to have originated in .the high North, King Clave the Saint being 
reported by Snorre Sturleson as having performed the ceremony. From 
thence, no doubt, it was carried to England, where the Confessor seems 
to have been the first to cure goitres." 

" In more recent times a prince, Hohenlohe, in Germany, claimed to 
have performed many miraculous cures, beginning with Princess Schwar- 
zenberg, whom he commanded in the name of Christ to be well again. 
Many of his patients, however, were only cured for the moment. When 
their faith, excited to the utmost, cooled down again, their infirmities 
returned. Still there remain facts enough in his life to establish the 
marvellous power of his strong will, when brought to bear upon peculiarly 
receptive imaginations and aided by earnest prayer." 

Several years ago an individual named Newton went about the country. 
It was his custom to hire a large hall and extensively advertise. Upon 
the day appointed he would meet the lame, halt, and blind, and after 
powerful exhortations and prayers, tell them to form in line and pass one 
by one before him. The emotional excitement and eager anticipation 
were sufficient in some instances to divert the hysterical patients who 
chanced to be among the number, so that in many instances there were 
spontaneous cures, the lame dropping their crutches, and starting off* at a 
lively gait, and the blind recovering their sight. 

Beard, in a paper upon "Mental Therapeutics," recently called 



HYSTERIA. 469 

attention to some experiments lie had been making. In many in- 
stances of .functional disease, lie assured the patients that their 
recovery would take place in some very short time, and found that at the 
time specified they returned completely cured. This procedure in cases 
of hysteria is of great value. I have repeatedly stopped an hysterical 
attack by a douche of cold water or by the exhibition of the cautery. 
Oftentimes, after the patient has been pleaded with, threatened, and 
dosed to no effect, a sudden fright or a sharp word or two will do more 
for her than anything else ; but the physician's demeanor to his patient 
should always be characterized by firmness and dignity, and not by harsh- 
ness or undue severity. 

It is a difficult matter to meet the peculiar manifestation of disordered 
mental expression in hysteria, for, as we all know, its phases are nume- 
rous. No two cases of hysteria are exactly alike, and consequently no 
two can be treated in the same way. A scolding occasionally does good, 
as I have just said; but in other cases it would aggravate the patient's 
condition. We cannot treat the hysterical woman in a trouble-saving 
and careless way ; and though many medical men hold that a sharp word 
or the direct appeal to the common sense, which is, however, absent here, 
is all that is required, it will be found that such a course is by no means 
a wise one to always follow. In many cases it is not best to tell the woman 
that she is " not to give way," or that she is " not to disgrace herself," for 
she is unable at once to use her will to overcome all the indirect agencies 
at work which are actiug upon her disordered brain. It is better to gain 
her confidence, and make her gradually exert her will in new channels 
by the performance of some act which requires the use of physical force, 
and this form of exercise may be prescribed by the physician. 

As to medication, we may make use of the motor-depressants, bromide 
of sodium, hyoscyamus ; or the mono-bromide of camphor in doses of three 
grains every hour, till quiet is obtained ; the spts. etheris co., chloroform 
or chloral, and valerian, or its compound, valerianate of zinc. The ob- 
stinate vomiting is occasionally stopped by hypodermic injections of mor- 
phine ; and a belladonna plaster over the irritable ovary will often prove 
to be an excellent form of treatment. All sources of reflex irritation 
should be removed as soon as possible, and uterine congestion overcome 
by leeching the cervix uteri, or hot douches. When there is much irrita- 
bility of the pelvic organs, I would suggest a combination of tr. cannabis 
indicus, and bromide of ammonia, with mucilage as a menstruum. 

For the ansesthesia and paralysis, strychnia and electricity are the best 
remedies of which I know, the latter being employed in its induced form, 
and the electric brush applied upon a dry surface. General treatment of 
a tonic character should be used when it is possible ; and iron, in com- 
bination with phosphorus or phosphoric acid, cod-liver oil, and sea-baths, 
together with local treatment. Local disease should be promptly eradi- 
cated if possible, uterine versions or flexions righted, and the menstrual 
function restored to its regular character. In those bed-ridden cases 
which are so discouraging and trying, we may use Weir Mitchell's treat- 



470 CEREBRO-SPINAL DISEASES. 

ment. A patient may lie in bed leading a very irregular life, and doing 
just about what she chooses, without improving in the least; while, if her 
room be well lighted, her diet changed, and her muscular tone kept up, 
a cure may be often wrought. 

I am not inclined to place any faith in the wonderful accounts of " me- 
talo-therapy " as used in these cases, and in several experiments I have 
made I have come to the conclusion that the possible increase in sensi- 
tiveness came entirely from the warmth of the metal applied or the irrita- 
tion of the foreign body. If the skin of a perfectly healthy person be 
subjected to slight rubbing or pressure, and a point be applied, he will 
feel the application much more acutely than in other parts in the vicinity. 
For acute paroxysms of hysteria, we may use large enemata containing 
assafoetida, and if a suppository of this drug in combination with bella- 
donna is inserted every night, a constant influence upon the patient is kept 
up which is very beneficial. 

HYSTERO-EPILEPSY. 

This interesting variety of nervous trouble has received a great deal 
of attention from Charcot,^ Dunant,^ Dubois, and Bourneville, as well as 
from many other writers, some of whom did not recognize its distinct 
character until after Charcot's valuable investigations had been announced. 

Tissot^ says that "the hysterical attack sometimes resembles epilepsy, 
so much so as to have received the name epileptiform hysteria, but the 
attack nevertheless does not possess the true character of epilepsy." 

Others, among whom are Briquet,* Landouzy, and Saunders, have also 
described the condition. 

Upon the authority of Charcot,^ the combinations of epilepsy and hys- 
teria take place under the following different circumstances : — 

1. a. Epilepsy being the primary disease, upon which hysteria is en- 
grafted, under the influence of emotional causes or at the time of puberty. 

b. After marriage (vide Landouzy's Case), the epilepsy having always 
existed. After connection, the hysterical feature of the attack is de- 
veloped. In this case the hysterical character of the epilepsy subsided 
when sexual excitement was interrupted by pregnancy. 

2. The hysteria being primary, the epilepsy is added thereto. A rare 
condition. 

3. Convulsive hysteria coexisting with petit-mal. 

4. An epileptic attack, followed by hysterical contractures, anaesthe- 
sia, etc. 

I have observed a form which slightly differs from any of the above. 
The patient, an epileptic, was seized occasionally with hystero-epileptic 
attacks during the menstrual periods, and at other times there was un- 



1 Lefons sur les Maladies du Systeme Nerveux, part i., Paris, 1872. 

' De I'Hystero-^pilepsie. ^ Maladies des Nerfs, quoted by Charcot. 

* Op. cit. 5 Op. cit., p. 324. 



HYSTERO-EPILEPSY. 



471 



complicated epilepsy. She has had epilepsy since the fifth year, when 
she was frightened by her mother, who threatened to beat her. 

Symptoms. — In an excellent pictorial work published by Bourne- 
ville and Regnard, the admirable clinical assistants of Charcot, a num- 
ber of plates are given, some of which I have reproduced with an ab- 
stract of the description by the authors. 

^" The prodromal features of an hystero- epileptic attack are ovarian 
hypersesthesia, the globus hystericus, cardiac palpitation, constriction 
about the neck, noises in the ears, violent beating of the temporal arteries, 
obscure vision, etc. -The immediate attack is ushered in by irregular 
respiration, oppression and dyspnoea, awkwardness of speech, amounting 
,to embarrassment, of which the following example, which occurred in one 
of our author's cases, may be presented. After the prodromal symptoms 
described above, the patient, with hesitation and difficulty, enunciated the 
words : " J'ai . . . I'a . . . respiration .... dif . . 
ficile . . . se . . ne . . . . serai .... pas 

. . . . malade . . . afin . . . de . . . pas . . . 
avoir . . . de nitrite d'amyle," in the way they are written. Some 
tumultuous heaving of the belly then follows, the eyelids palpitate 
rapidly, the look becomes fixed, the pupils dilated, the gaze is fixed upon 
some object above, then she loses consciousness. 



(Fig. 61.) 




Tonic Phase. — {Bourneville). 

The actual attack is characterized by an initial stage (^the tonic phase) 
of tonic convulsion. The entire body becomes rigid, the arms being 
usually stretched out, and the hands are turned in ; there is a movement 
of circumduction of the hands and forearms, the arms being drawn across 
the body, and the back of the hands brought together, so that the 
knuckles are approximated (see Fig. 61). The inferior extremities are 
stretched out, and drawn apart, the feet being in the position of equinus 
varus, but in other cases the feet may overlap each other, the toes being 



iSee author's review of Bourneyille and Kegnard's work, Am. Jour. Med, Science, 
July, 1879. 



472 CEREBRO-SPINAL DISEASES. 

strongly flexed. The face is contorted and suffused with blood, and the 
mouth is often widely opened, or in some cases tightly shut, the lips being 
compressed over the teeth. Kespiration is suspended, the pulse is with 
difficulty perceived, and the belly is immobile and contracted. The next 
phase is that characterized by tetaniform and clonie spasms, the head, 
which Avas drawn downwards and to one side, or backwards, returns to its 
normal position, the facial muscles become seized with clonic spasms, 
and the eyelids are opened and shut violently but somewhat slowly. A 
stertorous phase supervenes, the face becomes covered with large drops of 
sweat, the respiration grows noisy and violent, and there is frothing at the 
mouth. A period of repose then follows, when the respiration appears 
regular ; there are movements of swallowing, abdominal gurglings are 
heard, and undulations of the abdominal walls become apparent. The 
clonic phase, which has been described as the " stage of contortion," is 
expressed in two ways, which sometimes succeed each other in the same 
attack. 1. In clonic movements of the limbs and head, which is rolled 
from side to side. The face is red and engorged with blood, the neck is 
stiff, and the arms are stretched out and contracted, and after a time the 
patient falls violently to the bed, arising and falling again several dif- 
ferent times. At the same time the rigidity of the arras disappears, little 
by little. 

2. " The mouth is widely opened, the tongue is protruded ; she moves 
rapidly to the side of the bed crying oh ! oh ! (owe ! one !) The body 
becomes curved in opisthotonos. She rests on the back of the head and 
feet, her hair is dishevelled, the legs are convulsed and agitated by alter- 
nate movements of flexion and extension." (See Fig 62) . 

A new period of repose follows. 

By far the mo-t interesting phase of the disorder now makes its ap- 
pearance, viz., the period of delirium. In Bourneville's patients, and 
in fact those of other observers, the incidents of the previous life figure 
conspicuously in the delirium, and though there is a tendency to the for- 
mation of causeless hallucination of the horrible kind, in which reptiles, 
and such small animals as rats and cats figure at some stage, there is an 
old impression which serves as a field for the development of a delirium 
which is exhibited by gesticulations and facial expressions of fear, ecstasy, 
anger, mockery, erotism, and grief. 

The patient at this stage assumes an attitude and expression indicative 
of her emotional condition. She may remain lying upon the bed, her 
body inclined to one side, her arms resting by her side, her face upturned 
and wearing a beseeching look, which constitutes the " Attitude Passi- 
onelle " of Appeal, At another time she clasps her hands, sits up, turns 
her face upwards, and gives expression to words of supplication, such as 
these ; " Tu ne veux plus ? Encore . . ! " this being the " Suppli- 
cation Amoreuse." At other times the patient lies upon her back, her 
arms crossed over her breast, and her face wreathed with a most sensuous 
smile {erotisme). 

The variations of the delirium do not S3em to be at all x^egular ia 



HYSTEEO-EPILEPSY 



473 



their mode of appearance or constancy, but there is a general similarity 
in the form of emotional excitement and method of expression, and from 
an inspection of either of the cases, it would appear that for several days 
at a time there were convulsive attacks followed by delirium, in which 
scorn, mockery, fear, amorous ecstasy, subsequent repose, and either a re- 
turn of the delirium, or fresh convulsions, occurred. 

(Fig. 62.) 




Phase of Opisthotonos. — {Bournevdle). 

There may be fifteen or twenty attacks in twenty-four hours, or even 
many more, and some of these are aborted or irregular, at such times the 
only manifestations being those of a purely psychical nature ; the syn- 
copal attacks being examples of this kind. In rare cases the donie phase 
(or period of the grand movements) is followed directly by the extension 
of the arms at right angles from the body, so that an appearance is pre- 
sented which has been called Crucifiement, or the position of crucifixion. 

This is usually associated with the portrayal of various ecstatic states, 
which are termed by Bourneville beatitude, etc. The first of these is most 
strikingly portrayed in the plate which is here reproduced. (See Fig. 63). 

An occasional feature of one of Bourneville's cases was the complication 
of chorea, which was manifested at different times in the course of the dis- 
ease. It was of a rhythmic character, and involved the entire body, so 
that the trunk was drawn backwards and forwards, the forearms were 
flexed and extended, the hands were pronated and supinated alternately, 
and the legs and thighs flexed and extended, the right eyelid became 
closed, and the muscles of the right side of the neck were convulsed. 
This occurred in paroxysms, and was modified under ovarian 
pressure, the movements becoming less violent, and finally ceasing. 
When the compression was suspended, the movements began anew, and a 
violent contraction of the right arm and leg, which had lasted during the 
maintenance of pressure, disappeared. Ether was given, and again the 
movements were suspended, but a fresh contraction of the limbs of the 
right side took place. 

In one or other of these cases hemiansesthesia and ovarian hypersesthesia 



474 



CEEEBRO-SPINAL DISEASES, 



were observed from time to time. Contraction of various organs was 
quite frequent, and was sometimes provoked by ovarian pressure, as in 
the case just detailed, and different visual disorders, such as amaurosis 
and disordered color sense, were discovered, while hallucinations of 
vision were prominent in both cases." 

(Fig. 63 ) 




Beatitude. — (Bourneville.) 

The following cases were my own : — 

Case I. — A. P., set. 18, since the beginning of the menstrual epoch, 
has suffered from her present form of hystero-epileptic attacks, which 
have come on generally just after the cessation of the catamenial period. 
She has been very irregular, and has suffered from amenorrhoea, but there 
is no uterine disease that I can discover. This amenorrhoea has amounted 
to an entire cessation of the menstrual flow for several months at a time, 
during which she would have her attacks. Some of these attacks were 
like that I shall presently describe, and lasted for several days. There 
was no succession of attacks, but usually several severe but distinct epi- 
leptic seizures, and afterwards an hystero-epileptiform paroxysm- She 
had been in the Epileptic Hospital for some time, and had given a great 
deal of trouble by her irritability and mischief-making propensities. 
Her attacks at the hospital were three in number during one year,- each 
of them lasting from two to three days at a time, during which there 
was suppression of urine, vomiting, and hemiansesthesia, which in one 
instance was on the right and twice on the left side. 

Her most pronounced attack occurred while she was staying at her 
mother's house, where I was summoned to see her. This was on the 14th 
of March, 1877, when her mother came to my office, and told me that 
her daughter had been ill since the preceding Thursday ; that she had 



HYSTERO-EPILEPSY. 



475 



gone with her sister to see a friend ; and that while there she had been 
seized with a severe fit, and could not go home until the next day 
(March 9). She said that on her return her daughter complained of 
headache, pain in the back, over the ovaries, and abdominal discomfort, 
and as the time for her menses had come, she gave her a pill of aloe s 
and myrrh on Saturday, and another on Sunday night, with no result, 
and a warm hip-bath on Monday. (She had not menstruated since 
December 1876.) On Monday she had several severe epileptic fits, with 
frothing at the mouth, during which she bit her tongue, and went to bed, 
where she remained until I saw her. I went to the house, and found 
that she had been seemingly unconscious since Monday night, that she 
had been " frothing at the mouth " since that time, and that on Tuesday 
she began to mutter and talk to herself ; that she had had hallucinations 

Fig. 64. 




Hystero-Epilepsy. 

and delusions, some of them of a painful character, believing that she 
had been followed by a nurse from the hospital, whose intention was to 
kill her. When her mother entered the room, she berated her soundly, 
and was quite abu sive, indulging in obscene language. 

I found her lying upon the bed, lightly covered by a sheet. The mus- 
cles of her back were rigidly contracted, so that her position was one of 
opisthotonos ; her head was turned to one side, and her tongue was pro- 
truded. Her eyes were open, and the pupils widely dilated, and insen- 
sible to light. Her expression was blank, and she was apparently un- 
mindful of her surroundings. Her arms were drawn over her chest, and 
her forearms slightly flexed and crossing each other. Her thumbs were 
bent in, and covered by her other fingers, which were rigidly flexed. 
Her pulse was 124; temperature, 101.2°; respiration, 33. She was 
muttering to herself a disconnected string of words without any mean- 
ing, and continued them during my visit. She had not eaten for twenty- 
four hours, and I ordered milk and chloral hydrate in twenty-grain 
doses, to be forced into her mouth if she did not open it of her own ac- 
cord. 

On my return the next morning, the mother told me that she had had 
delusions during the night, and had cursed those of her family who ven- 
tured to approach her. I found that the rigidity of the previous day had 
become less marked, but that her right hand and forearm were beneath 
the lower part of her back. The right corner of her mouth was drawn 
downwards, and her eyes were still open, and the cornese anaesthetic. 



476 CEREBRO-SPINAL DISEASES. 

She did not know ma. Tempsrature 100^ ; pulse 10 S ; respiration 28. 
On the following m )rning Dr. Charles E. Lockwood of this city went 
with me to see her. She was then much better, and was less rigid, but 
the right hand was tightly clenched, and no persuasion would indace her 
to open it. Her toes were also flexed, and her right foot presented the 
appearance called by Charcot, * le pied bot hysterique." Her cornese 
were sensitive, and her pupils less dilated. There was some rolliug of 
the eyeballs from side to side, and patient occasionally sighed. Her 
pulse was now only 96, and was small and irritable ; the temperature 
was 99°. When sharply spoken to, she said '' Doctor," and relapsed into 
a state of stupidity, turning her head from right to left, and staring at 
the ceiling. She occasionally moved her tongue, as if her mouth was 
dry. Dr. Lockwood suggested the experiment of frightening her, and so 
we threatened the use of the cautery, the mention of which first brought 
forth remonstrance and afterwards a reply to our questions. 

Her mother stated that she had not passed urine for several days. I 
did not find a distended bladder, but when the catheter was introduced, 
it brought away about half a pint of light-colored urine. This suppres- 
sion of urine continued for several days.^ She arose from her bed the 
day after this last visit, and her menses appeared. Daring the next three 
or four days there was slight hemi anaesthesia of the right side. 

Case II. —A young lady, 19 years old, had been my patient for nearly 
a year, during which she had had on an average about one attack of 
haul mal in a week. Her epilepsy dated from the ninth year, and was 
not dependent upon any discoverable cause. At all times she is irritable, 
pettish, and techy, and leads a very irregular life. There was nothing 
remarkable about her attacks ; they were not very violent, nor were they 
connected with any hysterical manifestation. There was rarely any 
coma ; but the attacks were more severe about the time of the menstrual 
discharge, which was never abundant. On September 12, 1876, I was 
telegraphed for to see the patient. The day before my arrival, without 
any premonitions, she had had an attack very much like all the others, 
but instead of falling asleep she remained convulsed, and apparently un- 
conscious. She vomited two or three times, and became quite cyanotic ; 
so the local physician was sent for. He found it impossible at first to 
open her mouth to remove the substance which had collected therein and 
distended the cheeks, and it was only when he was assisted by others that 
he could do so. She was placed in bed, and remained in this state, the 
eyeballs rolling from side to side, the body drawn slightly to the right 
side, and the hands clinched. She became delirious during the night, 
and had delusions of a lively kind, like those of a patient with delirium 
tremens. Outbursts of hysterical laughter and jactitations of the limbs 
followed in the morning, and then she became quiet, but the muscles were 
somewhat rigid. I arrived at about 2 P. M., and found her lying upon 
the bed with open eyes and meaningless stare. Her right hand was 
rigidly abducted, and the bed-clothes were tightly grasped in her hand. 
The head was drawn so that the chin was approximated somewhat to the 
chest. The teeth were set together, and there was some grinding of the 
molars. She breathed noisily, there being an accumulation of mucus in 
the throat. Temperature 100.2^ ; pulse 83. The pupils were dilated, 



^ It is probable that this urinary derangement was of the form called by Charcot 
oliguria. 



HYSTERO-EPILEPSY. 477 

and seemingly unaffected by light. Pressure upon the right ovary 
caused her to shrink somewhat. Her abdomen was distended by flatus. 
During the night she became somewhat relaxed, and muttered unintel- 
ligibly, but in a petulant tone. She fell into an apparent sleep about 5 
A. M., her respiration being natural. She awoke at about 5 P. M. of 
the same day (the third), and though somewhat fatigued, arose and 
went about. She was not hemiansesthetic, but ischuria lasted for several 
days. 

An inspection of the cases of Charcot and others will enable the reader 
to detect certain symptoms which are alike in all the patients. 

Case III. — Eeported by Charcot. Marc , 23. Hystero-epilepsy 

dated from the 16th year; attended by hemiansesthesia and hemiparesis 
of left side. Daltonism of left eye ; frequent vomiting. Attack preced- 
ed by an aura and pain in left ovary. Attacks included three stages : a. 
Tetaniform contraction, epileptiform convulsions, h. Violent movement 
of trunk and lower extremities (period of contortion). Silly and discon- 
nected talking. Patient appeared to be semi-delirious, c. Laughing fits; 
attacks stopped by ovarian compression. 

Case IV. — Charcot. Cot., 21 years. Hysteria dated from the 15th 
year, and followed cruel treatment at the hands of her father, when she 
took to drink and became a prostitute. ' Local symptoms are : right hemi- 
ansesthesia, ovarian pain, permanent, and tremulation of the right lower 
extremity. Convulsions followed ovarian pain ; they are tonic, and she 
bit her tongue and frothed at the mouth. The second period followed at 
once, and was marked. The attack often terminated by movements of 
the pelvis, laryngeal constriction, crying attack, passage of large 
quantities of urine. Ovarian pressure moderated attack, but did not ar- 
rest it. 

Case V. — Charcot. Legr. Genevieve, 28. Hysteria dated from 
puberty. Permanent local symptoms ; left hemiansesthesia, ovarian pain, 
and mental peculiarities (bizarre). Aura quite marked, and so are 
cardiac palpitation and head symptoms ; attack may be divided into 
three stages : a. Epileptiform convulsion, frothing at the mouth, and 
stertor. 6. Movement of limbs and body. c. Period of delirium, dur- 
ing which she detailed the events of her life. Occasionally last stage 
would be characterized by hallucinations, when she would see crows, ser- 
pents, etc. She would at other times dance. Ovarian pressure arrested 
attack. 

Case VI. — Charcot. Ler., 48 years. Attacks date from early life, 
when she was frightened by a dog, and by the sight of the body of a wo- 
man who had been assassinated. Local symptoms : hemiansesthesia of 
ovary ; paresis and contractures of the upper and lower right extremi- 
ties, and occasionally the left. Attacks begin by ovarian aura, followed 
by epileptiform and tetaniform convulsions, after wdiich she assumed the 
most trying postures. At the time of the attack she falls into a delirium, 
during which she indulges in furious invectives, crying to imaginary 
persons : " Villains, robbers, brigands ! fire, fire ! Oh the dogs ! oh, I'm 
bitten !" these being suggested by memories of her childish fears. When 
the convulsive part of the attack is terminated, there follow : 1. Hallu- 
cination of sight, the patient seeing skeletons, frightful animals, spectres, 
etc. ; 2. A paralysis of the bladder ; 3. A paralysis of the pharynx ; 4. 
Finally, a more or less permanent contracture of the tongue. These la«t 



478 CEREBRO-SPINAL DISEASES. 

symptoms remain for several days, during wliicli it is necessary to feed the 
patient with a stomach pump, and then draw off her urine. 

Two cases, reported some years ago,^ resemble the more modern hys- 
tero-epilepsy so closely that I am inclined to infer that they were attacks 
of this disease. 

Case VII. — Arguinosa's Case. Woman, twenty years. Epileptiform 
convulsions first showed themselves during infancy, in consequence of 
head injury. They reappeared at puberty. While residing in the house 
of Dr. Arguinosa she complained of ovarian pains. The precursory 
signs of an epileptic attack soon showed themselves, and, on returning 
from a walk, " she had scarcely time to throw herself on a bed before she 
lost both sensation and motion. The skin was hot, respiration loud, pupil 
immovable, eyelids closed convulsively, limbs flexible, while the lips were 
convulsively moved, or else a sardonic smile sat upon them. Bleeding was 
about to be practised, when, all of a sudden, after some horripilations, 
the skin became cold and colorless, the pulse and respiration were sus- 
pended, and the patient appeared dead." 

Cold affusion to the head seemed to produce an effact The respiration 
then became agitated, the pulse strong, and violent convulsions, with 
tetanic rigidity (pleurosthotonos) set in. 

She became angry and irritable, screamed out. Noises in the room, 
light, and the steps of persons around her were sufficient to " draw her 
from her attacks of delirium." She had a presentiment of sudden 
death. 

" Two days following there were the same alternatives, the delirium 
occurring less frequently, and lasting a shorter time ; she slept but little 
that night (the 4tti) ; the next day the only symptom? noticed were aver- 
sion to water, light and air, with the pain of stomach previously com- 
plained of Oa the sixth day she asked for a bath, and the opium which 
she took in the evening. A stool brought on strong convulsions and 
noisy delirium. The women who were attending to her bBlieving her to 
be possessed by the devil, sprinkled her with holy water, which increased 
her furious cries and bizarre contortions. The following night was dread- 
ful ; the mouth full of foam, the eyes injected, and the delirium almost 
continuous. About ten in the morning immoderate laughter succeeded 
the previous symptoms. She ultimately died." 

Case VIII. — Ward's case. Mary P., aged 13. Measles at age of 7, 
and has ever since besn subject to cough and pain in the side. About 
one year ago she had her hrst epileptic fit, during which she attempted to 
bite and scratch the bystanders. She was not insensible, but delirious. 
The attacks came on at intervals for a fortnight afterwards, and they be- 
came much worse at the end of this time. Her arms were extended and 
rigid, and the fingers clenched. At other times she struggled violently, 
and the abdomen became swelled. She never became unconscious. Her 
dispositioa was changed, for she grew exeeedingly mischievous between 
the attacks, developing a prop3n3ity for climbing trees and playing the 
hoyden. Ovarian pain sometimes The attack is occasionally finished 
by a fit of laughter. 

The so-called hysterogenic zones have been described by Richer^, Char- 

^ Forbes Winslow's Psychological Journal, vol. ii. 
^Etudes cliniqnes sur I'Hystero-epi'epsie, etc., Paris, 1881. 



CATALEPSY. 479 

cot and Mills', the latter having written a most valuable article upon 
hystero-epilepsy which will be found to be very complete. These zones 
consist of limited cutaneous districts which, when subjected to pressure, 
electric excitation, blistering or hot or cold stimulation, are likely to give 
rise to, or on the other hand, modify or stop an attack of hystero-epilepsy. 
These are bi-lateral, and are situated above and below the mamma, over 
the ovaries, beneath the axillse over the ilia, over the seventh cervical 
spine and the upper dorsal region. The form of excitation varies greatly, 
whether the patient's surface is or is not hypersesthetic or anaesthetic, or 
in proportion to the severity and kind of impression. Occasionally, as has 
been ascertained, the excitation of these regions during an attack may 
modify the character of the delusions during the stage of delirium. The 
so-called erotogenetie zones of certain French writers include these as well 
as other spots — the palmar surface, the back of the neck, and the eyelids 
— which, when irritated during an attack are followed by changes in 
the character of the delirium, the patient indulging in erotic fancies. 

In simple hysteria, pressure or irritation of these spots may give rise to 
various dysasthesire. 

Charcot holds that a very important diagnostic sign is the reduced tem- 
perature. In epilepsy the temperature may even rise to 107.6^ F., while 
that of the hystero-epileptic rarely attaias a height of 100^ F. In the 
cases I have alluded to, Case I. presented all the prominent symptoms 
by him enumerated, and still the temperature was quite high. 

Treatment. — Nitrite of amyl has been recommended by the French 
authorities for the suppression of the attack. I would recommend nitro- 
glycerine for the same purpose, in doses of n^ v. of the solution spoken of 
on a previous page. It is of great importance that the pelvic organs 
be looked after. Dislocation of the ovaries, uterine flexion, or troubles 
of a like kind, will often be found to have much to do with the genesis 
of hystero-epilepsy. 

CATALEPSY. 

Definition. — A disease closely allied to hysteria, of extreme rarity, 
and characterized by a condition of muscular contraction and semi-rigid- 
ity, so that the limbs may be placed in constrained and awkward posi- 
tions, and remain so for some time. It is attended by loss of consciousness, 
and cutaneous anaesthesia. 

Symptoms. — The disease, like epilepsy, is characterized by attacks 
separated by intervals of greater or less duration, during which periods 
the patient is usually in apparent good health. 

After such prodromata as malaise, vertigo, headache, or functional tre- 
mor, the individual will suddenly be seized. He may be talking or eat- 
ing, when the particular act is arrested, the mouth remaining open, or the 
hand half raised. The muscles become rigid, but the limb may be moved 
by the physician or bystander, and if placed in a new position, no matter 

1 American Journal of Med. Sciences, Oct., 1881, p. 392. 



480 CEREBRO-SPINAL DISEASES. 

how awkward it will remain so fixed until the muscles are fatigued, 
when it drops. Individuals are reported to have remained for even 
an hour or two with legs or arms extended; and in one case I saw the pa- 
tient remained for half an hour with the right arm extended in a straight 
line from his shoulder, and the other extended above the head. The 
position was subsequently changed. The peculiar semi-rigidity of the 
muscles has gained for it the name flexibilitas cerea, on account of a " wax- 
like " mobility ; and there is none of the pronounced stiffness, or, on the 
other hand, limpness of the limbs, that usually attends the unconscious 
state. The surface of the body becomes quite cool ; the pupils are dilated ; 
respiration is shallow and scarcely perceptible ; and it is sometimes difficult 
to find the pulse, which grows thready, but nevertheless preserves its 
regularity. 

The skin is ansesthetic to an astonishing degree. Needles may be thrust 
into the tissues without the knowledge of the individual, and pinching, 
slapping, or other forms of cutaneous stimulation, produce no expression 
of pain. In a case of hystero-catalepsy, seen with Dr. D. B. St. John 
Roosa, I repeatedly thrust pins into the arms and legs of a young woman 
and watched attentively for some sign, but her expression was immobile 
and tranquil. 

It is stated that the electro-muscular contractility is not aflTected, but 
reflex excitability seems to be diminished or lost entirely, so that some- 
times it is almost impossible to determine whether the patient is alive or 
dead. The so-called trance states are examples of this kind, and cata- 
lepsy has undoubtedly led to burial alive in many instances. 

The ordinary attacks usually subside in a few hours, the rigidity grow- 
ing less marked, and consciousness gradually returning. The attacks, as 
a rule, follow each other in a series, and then comes an interval of normal 
health. In this mode of appearance and behaviour, the disease has been 
likened by Eulenburg to neuralgia "Strictly speaking, it is rather a 
cycle of attacks quickly following one another ; " and there are remis- 
sions characterized by a temporary return of consciousness, and then a fresh 
relapse, which evidently follows some internal irritation. In rare cases 
there is a sudden return of consciousness and an ability to perform volun- 
tary acts. The urine and feces are rarely passed in an involuntary manner. 

Unless the disease be due to malaria, it becomes chronic, and continues 
for years. If it is due to malarial poisoning, it usually assumes a regular 
periodic character, and is amenable to treatment. 

Causes. — Like many other neuroses, such as hysteria, epilepsy, and 
those of this class, mental excitement plays no mean part in the etiology 
of catalepsy. Fright, and other forms of emotional excitement enter into 
its causation. Injury and malaria may also be mentioned, while mastur- 
bation, venery, and intestinal worms are spoken of by writers generally. 
Jaccoud considers it to be a result or accompaniment of certain forms of 
melancholia (Melancholia attonita), and ecstacy. 

It appears as if it were more common in early life, and children are 
therefore nearly always the victims. Ansemic girls, or boys especially 



CATALEPSY. 481 

who study too constantly, are affected more often than those of adult life. 
Nearly all writers agree that the female is more subject to the disease than 
the male, and probably the delicate organization of the sexual apparatus 
has much to do with this. Hereditary influences seem to play a part in 
the etiology only so far as the general neurotic tendency is concerned. 
Families in which there is epilepsy, neuralgia, or insanity sometimes 
include cataleptic members. I have never heard, and I can find no re- 
cord, of transmitted catalepsy. 

Morbid Anatomy and Pathology. — Besides the autopsies made 
by Calmeil and other older writers, which, by the way, throw very 
little light upon the question 'of pathology, Schwartz made one autopsy, 
and Lasegue two, but nothing was found by the latter observer. 

Schwartz^ mentions the case of a boy "who, after an injury, had at first 
attacks resembling chorea, later catalepti co-tetanic attacks, and after two 
years died from ansemia and marasmus. There was found in this case, 
besides a serous efiusion in the arachnoid, a softening of the corpus 
striatum and optic thalamus, on the left side; along the posterior 
surface of the spinal cord, from the cervical to the lumbar enlargement, 
was a brownish-red, jelly-like mass, arranged in groups, covering the dura 
mater. The spinal cord seemed healthy. (There was no microscopic 
examination.)" • 

Catalepsy, which is associated with many other interesting perversions 
of consciousness such as somnambulism, stigmatization, etc., has received 
a great deal of attention, not only from the laity, but from scientific men 
of all ages. It is not my purpose to enter extenBively into the consideration 
of these various curious states. The lighter forms, such as the " catalepsie 
passagere" of Lasegue,^ have been induced, by mesmerists and others, by 
passing the hand over the face or body, or by closing the eyelids. The 
same condition may be induced by looking fixedly at some bright object 
held close to the face. 

A remarkable experiment of a popular nature, which I have repeatedly 
performed myself, is a curious instance of the susceptibility of certain 
animals to influences of this kind. If a lobster be placed head downwards, 
and gentle scratching of the back is made, it will become perfectly quiet, 
no matter how pugnacious it has been before, and will remain in this 
position for some time. 

The general opinion in regard to the pathology of the affection is that 
the peculiar muscular condition is due to an increased muscular tone, 
which probably depends upon impaired voluntary control, so that the 
muscles respond to trivial irritation reflected upon the spinal ganglion 
cells. 

Volition is checked just as it is in hysteria; and when we consider 
the theory of " expectant attention," advanced by Carpenter, the genesis 
of some forms of catalepsy is easily explained. These are the varieties in 

^ Quoted by Ealenburg in Ziemssen's Encyclopaedia, vol. xiv., translation. 
2 Archives Gen. de Med., 1865. 
31 



482 CEREBRO-SPINAL DISEASES. 

whicli the individual becomes cataleptic when influenced by another. The 
time has not yet come for the admission of mooted subjects like trance 
and double consciousness into text-books for students ; I therefore await 
the further development of the subject, which at present is in a chaotic 
state of confusion. 

Diagnosis. — The waxy flexibility, which is pathognomonic, is not a 
feature of any other disease, and this, taken in connection with the loss of 
consciousness and anaesthesia, makes the diagnosis a matter of certainty. 
The only point which should interest us is the possibility of simulation. 
Numerous instances of so-called stigmatization come under this head. 
There is abundant opportunity for detection, however ; and electricity, 
mental influence, and strong cutaneous revulsives are recommended should 
we suspect malingering. 

Prognosis. — When the cause is emotional, or when there is a malarial 
influence, the individual's chances are remarkably good. It is only when 
the disease appears in a subject of very marked nervous temperament 
that there is any reason to give a bad prognosis, and such cases are chro- 
nic. A fatal termination is a very remote possibility. 

Treatment. — Electricity in its induced form seems to be indicated 
for the abortion or relief of the paroxysm, and amyl nitrite may be re- 
commended for the same purpose. Should there be malarial influences, 
quinine, arsenic, or iron are of course in order. Curare, bleeding, and 
many other forms of treatment have been useless. In the transitory 
affection (catalepsie passagere) cold water douches, or diff*usible stimulants, 
are resorted to. The cataleptic and hystero-epileptic conditions are often 
attended by very great flatus, and when this is removed the patient quite 
often immediately recovers. An ounce or so of the tincture of assafoetida 
may be put in a quart of hot water and the woman is to be given 
an enema therewith, a folded napkin being held by the nurse over the 
anus. In other cases the rectal tube, such as is used by Emmet, may be 
tried. I would strongly discountenance a modern operation for the removal 
of the ovaries. I have seen one case where this was tried. The result 
was death within three or four days. There are so many causes that may 
enter into the production of catalepsy that it seems an unwarrantable 
assumption to fix upon the ovaries as the offending organs.^ 

1 The Principles and Practice of Gynsecologv, 1st Ed., p. 201. 



CHOREA. 483 



CHAPTEE XV. 

CEKEBRO-SPINAL DISEASES (Continued.) 
CHOREA. 

Synonyms. — St. Vitus's dance ; St. John's dance ; ^ Paralysis vacil- 
lans ; Tarantismus ; Choree ; Veitz tanz, etc. 

Definition. — Chorea is a disease characterized by involuntary and 
disorderly movements of the muscles, is unattended by loss of conscious- 
ness and cutaneous sensibility, and may be connected with paresis of cer- 
tain groups of muscles, or those of one side of the body. 

As early as the fifteenth century, a species of religious delusion appeared 
in Southern and Middle Europe, in an epidemic form, and was connected 
with certain saltatory and muscular phenomena, which gained for it the 
name of St. Vitus's dance. 

This is described by various writers as a condition of religious excite- 
ment characterized by gesticulation, contortions of the body, and leaping, 
while the patient generally screamed or howled like an animal. This 
peculiar state was supposed by the older writers to be demoniac possession, 
and many victims were made to undergo the ordeal, or were put to death 
by the sword, or burnt at the stake. Under the influence of their condi- 
tion they sought the shrine of St. Vitus, which was situated in a small 
chapel near Zabern. Here they were cured by the priests, who sang 
masses and removed the disorder.^ 

Various epidemics appeared subsequently, but the disease gradually 
became divested of its noisy character. In Italy a dancing disease, sup- 
posed to be due to the bite of the spider, and which received the name of 
tarantism, made its appearance in the early part of the sixteenth century, 
while at the same time, a peculiar outbreak occurred at Amsterdam, 
where seventy children of the Orphan Asylum became possessed. They 
climbed the walls, swallowed needles, hairs, pieces of glass, and other in- 
digestible substances, and " distorted their features and limbs in a fearful 
manner."^ 

At other places the same thing occurred, and until the end of the seven- 
teenth century, when there was some decrease in superstition, instances of 
this kind of chronic disorder were common. 

^ For a most entertaining description of this affection read Hecker's Epidemics of 
the Middle Ages, third edition, Sydenham Society's Transactions. 
^ Reynolds's System of Medicine, vol. ii. 
^ Scheie de Vere's " Modern Magic," p. 357. 



484 CEEEBRO-SPINAL DISEASES. 

Symptoms. — The beginning of a simple case of chorea may be the 
following : The patient, a boy of ten years, who attends school, becomes 
irritable, loses appetite, and does not care to go out and play with his 
fellows. He becomes pale and thin, and sits by himself In a little while 
some movement of the hand or fingers, some twitching of the face, or 
dragging of one foot when he walks, attracts the attention of parent or 
teacher. He may be punished, with the idea that such movements are 
the result of bad habits or viciousness, but it does no good, and probably 
increases the trouble. These jactitations cease at night, when he rests un- 
easily, and is disturbed by bad dreams. This is the condition in which 
we find the patient. What is the course of the disease? If he is neglected, 
it will not be long before the convulsive movements become general. The 
feet may drag along as if paralyzed, and such is the case. He will be 
unable to button his clothing, or attend to his little wants, and may need 
the careful and constant attention of his friends. The vocal cords may 
be afiected, and there is as a result a certain aphonia, so that phonation is 
husky and subdued. Inco-ordination of the lips and tongue gives rise to 
difficulties in articulation, which are quite distressing, the words being 
" snapped " and cut short. Mitchell uses the term " habit chorea " for a 
light form of the trouble, which consists perhaps only of some repeated 
grimace, or shrugging of the shoulders. 

The symptoms are worthy of separate consideration, and we will pro- 
ceed to discuss them in their order of importance. 

1. Motility} — The spasms, as I have said, are clonic, and are more 
often unilateral than bilateral. The right hand is usually affected first, 
then the leg of the same side may follow, and finally the other side may 
be implicated, so that the movements are general. The arm is usually 
involved before the face, though in several of my personal cases the first 
symptom noticed was a slight twitching about the mouth, and an awkward 

1 In an excellent report of 80 cases of Chorea,^ made by Dr. G. S. Gerhard, of the 
Philadelphia Orthopsedic Hospital and Infirmary for Nervous Diseases, the following 
points were observed : — 

Movement. — In 27 cases, general. 

11 ," '' but marked on right side. 

10 " " " '* left 

32 " unilateral, 20 on right, 12 on left side. 

In a certain number of these cases the movements shifted to the other side. 
Paralysis. — Partial paralysis noted in 17 cases. Loss of power in 10 instances 
confined to right side, in 7 to left. 

Age. — Under 10 years, 23 cases, 9 m., 19 fem. 

From 10 to 20 " 52 " 18 " 34 " 

Total, 80 " 27 " 53 " 

Cure in 56 cases, improvement or ** result unknown " in 24 cases. 



* Amer. Journ. of the Medical Sciences. 



CHOREA. 485 

tendency manifested by the child to open the mouth and draw its breath 
while speaking. In another, the little boy first attracted the notice of his 
mother by movements of the alse of the nose. 

I do not think that the movements in chorea are always increased by 
the effort of the will to stop them, as is the case in sclerosis, in which disease 
the tremors are exaggerated by any voluntary attempt of the individual 
at control ; and I have often been led to suppose that chorea might be 
divided into two varieties, viz., one in which the movements are increased 
with the exercise of the will, the other when they are most violent in a state 
of rest. The movements of the hands are characteristic, I think. There 
is a prehensile movement of the fingers and a rubbing of the ball of the 
thumb and ends of the fingers. There is swinging of the arm, and a 
shrugging of the shoulder, as if the patient had on large or uncomfortable 
underclothing. 

There is a trivial point which may perhaps be of interest, and I only 
mention it because it is unique. I allude to the habit which these little 
patients have of rubbing the seam of the trowsers leg by the hand which 
is affected, for these movements often go on most actively when the arm 
hangs by the side, and when the attention is not directed to it. In other 
diseases just such " little straws " will once in a while give a serviceable 
hint; for instance, in commencing paresis of any kind of the lower limbs. 
If we examine the tip of the shoe, we will find the sole to be worn down 
on one side of the body. In locomotor ataxia we will find a reduction of 
the heel. When these little patients are worried or embarrassed, the 
movements are greatly increased, and this isone of the strong features of 
diseases of this kind. I have at present a patient at the Hospital who is 
almost quiet when in the presence of people he has been associated with 
for some time, but every new face seems to excite him to such a degree as 
immediately to give rise to the most violent movements. 

The loss of power, which is very often a phenomenon of chorea, is 
nearly always one-sided, and when it exists to a marked degree, may 
greatly affect the patient's walk, so that he drags his foot in a helpless 
manner. Handfield Jones thinks that the want of power is a constant 
feature of the disease. Such paresis is extremely variable, however, in its 
extent. Muscular exertion is distressing, and he may not have the power 
to perform some of the least fatiguing actions of daily life without great 
prostration. 

The muscles that are most paralyzed are always those which have been 
the seat of the most violent spasm. 

Semation. — There may be pain in the wrists if the spasms are severe, 
or the skin may be anaesthetic ; such loss of sensation being confined to 
the w^hole paralyzed side, or to a single limb. 

Mental Condition. — Irritability of temper and emotional excitement 
are present from the beginning, and the child is restless, sleeps lightly 
and is tortured by bad dreams. Study or mental application is an impos- 
sibility, and spells of crying are quite familiar evidence of the disease, 



486 CEREBRO-SPINAL DISEASES. 

especially in the earlier stages. Chorea may exist in a very severe form 
when there is a grave exciting cause ; and the convulsive movements may 
be so violent as to render it necessary to bind or hold the patient in bed. 
At the request of Dr. J. P. P. White, of New York, I saw with him a case 
of this kind. 

The little girl, who was about ten years of age, had arrived in New 
York after a sea-voyage, during which the symptoms began. We found, 
her agitated by violent spasms of all four extremities, which had lasted 
for several days, and it required constant watching to keep her from 
throwing herself out of bed. They ceased partially during sleep, but 
this needed repose was denied her to a great extent. Her skin was hot, 
and her pulse bounding and full. She was perfectly conscious, but com- 
plained of pain in the wrists. I inferred, from the general character of 
the convulsions, their constancy and violence, and from other symptoms, 
that there was some form of eccentric irritation; and an anthelmintic ad- 
ministered by Dr. White brought away a tapeworm several yards long. 
The movements disappeared in a very short time. 

The urine had been found by Walshe and Bence Jones to be of much 
higher specific gravity than in health, and to contain an excess of urea. 
It may vary from 1030 to 1040, and is loaded with the oxalates and 
lithates. 

Another form has been described which is characterized by paroxysms, 
during which the patient may perform the strangest antics. Her condi- 
tion before and after the attack is one of quietude, but without warning 
she becomes agitated by spasms, rolls on the floor, jumps in the air, or 
rushes about the room. Wood reports a case of this kind, in which the 
patient, a young married woman who had been slightly ill for some time, 
developed this paroxysmal variety. " The paroxysms themselves were not 
always of the same kind. At one time she would be violently and 
rapidly hurled from side to side in the chair in which she might happen 
to be sitting, or else, suddenly gaining her feet, she would go on jump- 
ing or stamping for a while ; or, she would rush around and around 
the room, and would rap with her hands each article of furniture which 
lay in her course ; or she would spring aloft many times in succession 
and strike the ceiling with the palm of her hand, so that it became ne- 
cessary to remove some nails and hooks which had done her an injury ; 
or she would dance upon one leg with the foot of the other leg in her 
hand." 

A professional friend has recently informed me of a case of this kind 
which came to his knowledge, in which the woman was affected very much 
in the same way as the patient of Mr. Wood, and that on one occasion she 
created great commotion by attempting to climb one of the stanchions in 
the cabin of a steamboat. 

These cases are so rare, however, that they only deserve to be men- 
tioned en passant as examples of the irregularity of the disease, and are 
somewhat like the original dances of St. Vitus and St. John. 



CHOREA. 487 

The following case illustrates a very curious phenomenon of motility 
which I lately noticed : 

The patient, a boy of ten years, was brought to me by his father for 
treatment, after having been seen by many practitioners, who did not 
agree in regard to his condition. I saw that his movements were choreic. 
Questioning revealed the fact that he had never been a strong child, but 
had always been disposed to nervous troubles ; even the exanthematous 
fevers, which, like other children, he had had, were generally connected 
with stupor, and other evidence of susceptibility of the nervous substance 
to blood-poison. He never had any rheumatic or cardiac affections, and 
I could hear nothing to indicate valvular trouble. The heart-sounds were 
sharp and quick, however. Four years ago he began to decline, became 
weak and anaemic, was irritable, moody, and bad-tempered. His appetite 
was capricious, and he preferred sweets to other food. In the summer of 
1872 the movements in the hands and arms began, and soon became gen- 
eral. His rest was uncomfortable, and he started up in his sleep and 
cried out. When I saw him four months ago he was a pitiable object. 
His movements were general. He was unable to hold anything, and was 
powerless to perform any voluntary actions except those of a gross kind. 
He could not unbutton his clothing or put on his cap ; his mother even 
had difficulty in making him walk. 

Variety of Ifovement. — Head was violently agitated, there being con- 
tractions of the sterno-cleido-mastoideus. He " sucked in his cheeks," and 
pursed up his mouth, smacking the lips. Other facial contortions were 
violent. He winced spasmodically, and there was constant motion of the 
eyeballs. 

The arms were in constant motion, but the right was not affected so 
much as the left. The right arm and hand were slightly paretic, and he 
was able to force the column of fluid in the fluid dynamometer up to 16^, 
which is equal to 15 lbs. pressure to the square inch. The left forced it 
up to 18°. 

The legs. The right leg was also slightly paretic. The toe of the shoe 
was worn down to some degree, although the walk was not noticeably 
affected. 

There was an uneasy rolling of the pelvis when he sat down, and the 
legs were not entirely under his control. There was pain in the wrists 
and ankles. Under proper management of his diet he gradually improved, 
and at the last visit was nearly well. I noticed then for the first time the 
following peculiar state of affairs. When sitting in front of me, I told him 
to raise his hands, one after the other. The right hand he raised promptly, 
but the left he could not, unless he took hold of the wrist with the other 
hand, and lifted it. This condition struck me as remarkable, especially 
as he had to repeat the process of aiding with the right hand. 

The left hand and forearm might be paretic. There was no loss of 
electro-muscular contractility, however, but, if anything, it was increased. 
The muscular power, tested by the dynamometer, was found to be even 
better than in the other hand. There was no atrophy. With these facts 
in view, it seemed improbable that this should be the cause. 

It was found that when the other hand was held down, the boy was 
able to lift his left hand unissided, and even to raise a dumb-bell weighing 
10 lbs., but as soon as the other hand ivas released he was unable to re- 
peat it. 



488 CEEEBRO-SPINAL DISEASES. 

To determine whether this was the result of any bad habit, I ascertained 
from the father that his son had never used one hand to lift the other till 
a few weeks ago. 

In adult life forms of chorea are met with which in nearly ev^ry respect 
resemble those of infancy. Sometimes pregnancy is the cause, and in 
other cases prolonged emotional excitement, and more especially grief, 
are in some way connected with the development of the disease. 

My case-book contains the records of several of these examples, and 
their form is usually of that kind which is known as hemichorea, and very 
often seems to be dependent upon some true organic lesion. In this form 
the exercise of the will to stop the movements is generally provocative of 
a decided increase in their violence. The patient is unable to carry 
food to his mouth, to manage his clothing, or to perform any little acts 
of necessity. He fears to make any attempts in the presence of other 
people, and this is especially the case before strangers. I have already 
alluded to one instance of this kind. In another patient the mere sugges- 
tion of meeting a new physician was sufficient to aggravate her convulsive 
movements. 

The chorea occurring during pregnancy generally disappears before 
parturition, and Jaccoud considers that it may lead to miscarriage, and 
he has found the mortality greater than in any other form. I am not 
disposed to agree with him as to the serious character of the disorder. 

An instructive case of this disease is subjoined : — 

Mary K., set. 24, entered the Epileptic and Paralytic Hospital July 
10th, 1877. She is of nervous temperament, and gives a family history 
of nervous disease. Her sister has epilepsy, and a brother has infantile 
paralysis. Up to the fifth day of June, 1877, she was perfectly well. 
While in bed she was awakened by a storm at about 3 A. M., and was 
greatly frightened by the loud claps of thunder and the vivid lightning. 
She arose and fell to the floor, where she lay for some time, crying, but 
found no difficulty in arising, there being no paralysis. The next day 
she felt " a cramp " in the left side, and the leg and arm were spasmodi- 
cally contracted, and afterwards began to twitch. There is no profound 
loss of power whatever, but some slight paresis of the left side, and a de- 
cided hypersesthesia of this part of the body. The left upper and lower 
extremities were convulsed by choreiform movements, the hand being 
more agitated than the leg. The strength of grip is decidedly weakened, 
and she is only able to force the fluid index in the dynamometer up to 8°, 
while with the other hand she raised it to 14°. There is some dragging 
of the foot when she walks. She does not sleep, but requires chloral and 
other hypnotics. She is in her seventh month of pregnancy, and it was 
decided not best to try any very active treatment. Arsenic was given, 
however, in the form of five-minim doses of Fowler's solution, and. she 
became more quiet under its use. At no time has she shown any indica- 
tion of impending abortion, and though feeble and ansemic, she is able to 
go about and enjoy herself in a limited way. 

Aug. 25, Fowler's solution increased, so that she takes tt^x, t. i. d. 
Movements somewhat lighter. 
Sept 20. Gave birth to a healthy boy after a short labor. 



CHOKEA. 489 

Oct. 10. Cured. Discharged. There Avas no special temperature 
variations at any time. 

A case of interest is that of — 

Lena C, set. 44 ; Germany ; married. Her mother had chorea at the 
same age. About four years ago, without any appreciable cause, convul- 
sive movements of the whole body began. These were not general at first, 
and were limited only to the upper extremities. The movements are 
bilateral, and agitate the hands more than any other part. The facial 
muscles are slightly affected, and there is a jerking upwards of the corners 
of the mouth, more especially on the right side. The movements are neither 
aggravated nor controlled by the will, but cease during sleep. Her cutane- 
ous sensibility is in no way affected, and her sight and hearing are both 
good. She has a strange habit of clutching her dress in front, probably 
to steady her hands, and when spoken to she seems greatly disconcerted 
and moves more than ever. 

June 25. Fl. ext. conii, 1T[ xl, t. i. d. ordered by visiting physician. 

2Qth. No marked toxic effects of the drug apparent, except dilatation 
of the pupils ; and the patient says that there is a " complete lightness of 
the body," and that "she could fly." Some improvement in movements. 
With a strong voluntary effort the movements are stopped for a time. 

July 10. Great improvement ; patient can hold her arms quite steadily. 
Discharged at her own request Dec. 15, 1875. 

She re-entered Dec. 22, 1875. I found the patient in probably the 
same state in which she first came into the hospital. She is a spare, tall 
woman, very restless and emotional. She cannot express herself at all, 
for when she attempts to speak the tongue refuses to do its part in arti- 
culation, and the result is the utterance of ill-arranged sounds, which are 
not properly formed into words. She smacks her lips, and " clicks" her 
tongue against the roof of the mouth, and the sounds which come forth 
are tremulous and agitated, and just such as one would expect to hear 
from a person who was agitated by some great fear. The contortions of 
the arms are very violent and irregular, and almost defy description. 
The body seems to twist upon the pelvis ; the arms are thrown backwards 
and forwards, and the hands and fingers are constantly working. She 
seems to have no volitional control over her limbs, and has very little 
muscular force. She walks without any apparent embarrassment, but 
when seated the movements in the lower extremities are more active than 
when she stands up. She was somewhat analgesic, as was demonstrated by 
pinching. Treatmeat with strychnine considerably moderates the violence 
of the spasmodic movements. 

Chorea may often present a periodic character, especially if malaria 
enters into its causation. The tendency to relapse is quite a striking 
feature, and, in many cases which I have seen, it appeared either during 
the early fall or spring, and reappeared the following season. ^Weir 
Mitchell, who has presented some very interesting facts regarding the re- 
currence of chorea -of 80 cases collected by Dr. Gerhard, '.^5 had attacks 
before — some of them several times. 

I have two patients now under treatment who have had attacks every 
spring for the past four years, but in these as well as other cases I find 

^ Treatise upon Diseases of the Nervous System, especially of Women. Phila., 1881. 



490 CEEEBRO-SPINAL DISEASES. 

the disease diminishes in violence, and the attack in duration, as it is re- 
peated. Mitchell has observed cases in which the recurrence of attacks 
was irregular, a year or two having intervened between them, and such 
is my experience. 

Chorea may be accompanied by other nervous troubles, or exist in an 
uncomplicated form as a result of debility arising from repeated nervous 
exhaustion or fresh eccentric causes. In one case I found it to appear 
as soon as cold weather came, and at the same time an extensive eczema 
upon the calves of the legs and scalp was developed. This disappeared, 
together with the movements, under the use of arsenic and oil, but both 
reappeared the following winter. Dr. E. Frankel has reported a similar 
case, and I have no doubt there are others who have had a like experi- 
ence. The disease usually wears itself out in a short time, the tendency 
to relapse rarely lasting after puberty ; and if a cure can be effected, the 
maintenance of a high standard of general health and certain precautions 
as to overwork or study prevent a return. 

Causes. — Various writers agree that the disease is confined to the 
period between the third and fourteenth years, and this has been my ex- 
perience. I do not know of a case under three years, but others have 
seen the disease in younger children. Watson limits the time at 
which chorea may appear to the period between the first and second 
dentitions ; and Hillier of Great Ormond Street Children's Hospital, has 
given a table, which is referred to by Radcliffe. He found that of 422 
cases at the above institution, 104 were between the ages of ten and 
twelve. Niemeyer believes the malady to be very rare before the sixth 
year and after the fifteenth. Girls seem to be more often affected than 
boys, for what reason I cannot say, except that it may be the more 
delicate organization of the former, and the preparative changes going on 
before menstruation. 

Mitchell has gone to great trouble to collect statistics showing the in- 
fluence of season and meteorological changes. He finds that March and 
April are the two months in which the attacks are more frequent, con- 
firming the observations of other writers; and that the rise and fall of the 
line of humidity and temperature play a decided aggravating or modify- 
ing influence. Mitchell also has ascertained that chorea is very rare 
among the blacks. 

When the disease appears after puberty, it generally takes an 
eccentric form, or it may be due to central organic changes, or fol- 
low hemiplegia. This latter form, denominated by Mitchell post-para- 
lytic chorea, has already been described. In chorea there is a general 
derangement of the dige-tive organs and loss of appetite and constipation 
and palpitation are quite common alterations of function met with in 
these cases. In the anaemic patients, and they are generally all so, there 
is often an aortic murmur, and the skin is pale and cool. 

The existence of cardiac disease or the previous history of rheumatism 
is considered by many authors to have much to do with the causation of 
the disease. Romberg, Hughes, and West, besides many others, have so 



CHOREA. 491 

decided ; and when we consider the pathology of chorea, it will ap- 
pear to us very reasonable. Of 104 cases of chorea at Guy's Hospital, 
but 15 of the number were free from any indication of cardiac or rheuma- 
tic diflBculties. 

The disease often follows scarlatina or other zymotic febriculse, or takes 
its origin from an attack of acute rheumatism, or whooping-cough. It may 
result, and generally does, from some directly exciting causes, such as over 
study, bad air, or food, worms, or sudden fright. My recent investigations 
in regard to the occurrence of the disease among school children revealed 
the astounding fact that over twenty per cent, of young school children of 
the public schools of New York were affected with choreic affections of 
greater or less gravity.^ West expresses it as his opinion, that over-study 
is a common cause, and my investigations are sufficient to prove this. 

Many cases are supposed to result from association of unaffected chil- 
dren with those who are the subjects of chorea. Niemeyer alludes to the 
prevalence of this " mimetic form" among boarding-school pupils. This 
view has been very popular with the laity, and I am convinced has some 
importance, still, I cannot but think that the influence of example has 
been grossly exaggerated. 

Malaria seems to play a decided part in the etiology of the disease. 
This was pointed out by Kinnicutt, who reported some interesting cases 
in which the movements were aggravated at certain hours on alternate 
days, and were characterized by something like periodicity. 

Morbid Anatomy and Pathology. — Comparatively few cases of 
fatal chorea have been reported. Twenty-two of these are brought for- 
ward by Dr. Dickinson, whose excellent article upon the pathology of 
chorea deserves the attention of every student of neurology. One case 
has been reported by Ellischer,^ which is instructive, as it exhibits 
changes in the nerve-trunks; and Ogle,^ Kirkes,^ Hughes,^ Romberg,'^ 
and See \ have made autopsies in other cases. The connection between 
disease of the heart and the neurosis under consideration has been 
studied perhaps most extensively on account of the occurrence of rheu- 
matism and valvular trouble as a complication in many of the cases. In 
Dickinson's cases the heart was found to be healthy in five ; in the 
remaining seventeen the following lesions were observed : — 

Kecent vegetations on mitral valves only, seven. 

'' '' " " with old thickening, .... one. 

1 Am. Psychological Journal, Feb. 1876. A number of papers containing questions 
were sent to the public school teachers of this city. In most instances the answers 
were intelligent and satisfactory. The cases alluded to above varied from movement 
of the hands and twitching of the facial muscles to general movements which attracted 
the attention of visitors. 

2 Archiv. fiir Path. Anat., etc., Bd. Ixi. 

3 Brit, and For. Med.-Chir. Review, January, 1868 ; Med Times and Gaz., 1866. 
* London Med. Gazette, 1850; Med. Times and Gaz., 1863. 

^ Guy's Hospital Reports, vol. iv., 184G. 

^ Op. cit. 

'^Referred to by Ziemssen, 



492 CEREBRO-SPINAL DISEASES. 

Recent vegetations on mitral and aortic valves, one. 

Recent vegetations on mitral and aortic valves, with pericardial 

adhesions, two. 

Recent vegetations on mitral and tricuspid valves, one. 

Recent vegetations on mitral and tricuspid valves, with pericar- 
dial adhesions, one. 

Recent vegetations on mitral and aortic valves, with recent peri- 
carditis, two. 

Recent veg etations on mitral valves, with old pericardial adhesions, one. 

Of the patients affected with recent endocarditis, the chorea in 6 ori- 
ginated from rheumatism, in 2 from mental causes, in 3 from uterine, in 
1 from rheumatic and uterine, in 2 from mental and uterine, and in 3 
from unknown causes ; thus showing the connection between the rheu- 
matic origin and the cardiac changes. 

The brain and cord were affected in 11 cases, there being congestion, 
softening, and appearances similar to those noted by the other observers 
I have mentioned. 

In one of his cases (No. V.) he made very thorough microscopical 
examinations, and I present his account of the appearances noted : " Sub- 
sequently sections from almost every region of the brain were examined 
microscopically. They were in most instances natural, the nerve-cells 
invariably so, save some injection of the vessels, not enough to be de- 
cidedly morbid ; though the veins were much distended, in particular 
about the dentate bodies of the cerebellum, the vessels and their canals 
were normal. There was no extravasation, effusion, or erosion. Two 
situations, however, were remarkable exceptions to these statements. In 
the deeper white matter of one of the cerebral convolutions were many 
conspicuous spots, which consisted of accumulations of crystals of hsema- 
tine mingled with indefinite debris, probably of nervous origin, swelling 
the canals around the arteries which still remained distended with blood. 

" The other region referred to as the seat of significant change is that 
of the corpora striata. These bodies were more minutely injected than 
the rest of the brain. The capillaries, as well as the larger vessels of 
both classes, being packed with blood-corpuscles and numerous spots, 
striking objects under the microscope, were closely set in their substance. 
These consisted each of an artery in section, empty, crumpled and col- 
lapsed, and surrounded by a mass of globular debris, which had been 
formed at the expense of the surrounding tissue. They had evidently 
been produced by a solution or destruction of tissue around the vessel 
consequent upon effusion from it, the result of injection which had now 
ceased to exist. In time these mixed effects of extravasation and disin- 
tegration would have disappeared and left mere vacuities. 

"The spinal cord displayed loaded vessels and eroded fissures, such as 
were seen in every other instance examined. In addition to these com- 
mon changes, the gray matter had undergone extensive transformation of 
the kind to which the term sclerosis has been given. This was slight in 
the cervical region — extreme throughout the dorsal — absent from the 



CHOREA. 493 

lumbar. The change was confined to the gray matter, which it affected 
on the same side of the cord nearly symmetrically. In the dorsal region 
it involved at least a third of the gray matter as seen in section; the 
affected portions on each side being adjacent to the attachment of the 
transverse commissure, and at the root of each posterior horn. In the 
cervical region, though the change was less extensive, its position was the 
same. The altered gray substance had been converted into a wool-like 
entanglement of curving areolar fibers, among which nerve-fibers could 
be sometimes traced, especially near the edges, but from which all other 
nerve-elements had disappeared, leaving a mere confusion of connective 
tissue. The nuclei proper to the healthy structure were present, but had 
undergone no increase, nor was there any other evidence of fibroid or 
connective new growth. The change seemed to consist essentially of a 
destruction and removal of the nervous elements, their fibroid skeleton 
only remaining." 

A fatal case of chorea was reported by Dr. Jas. H. Hutchinson.^ The 
heart was found affected, the aortic valves incompetent, the leaflets being 
" swollen and softened," and the aoria was atheromatous above the sinus 
of Valsalva. 

Ellischer,^ who made an autopsy, found that the vascular changes in 
the brain were marked, the walls of the vessels being changed, and the 
surface covered by dark granules. In certain places the calibre of the 
vessels was narrowed, and there was an accumulation of blood-corpuscles, 
and consequent effusion of the watery parts of the blood. Some of the 
vessels contained coagula. The connective tissue about these vessels was 
thickened and increased in size, and contained yellow pigment and 
granulated nuclei. The large ganglionic cells in the brain were filled 
with pigment, and the cell contents much changed. Sections of motor 
nerves exhibited red patches and destruction of nerve-fibers. These 
changes show, then, great vascular alteration, and degeneration of nor- 
mal nerve-tissue. 

In regard to the pathology there is much dispute, some observers con- 
sidering it to be but a functional condition, while others are well satisfied 
as to its organic nature. 

The original observations of Kirkes first demonstrated the relation be- 
tween chorea and rheumatism. Ogle contends that this relationship (or 
at least the evidences of rheumatismal causation in the brain, such as 
emboli) is only demonstrated by fatal cases. He considers the excess of 
fibrin in the blood to be only the result of the same influence that pro- 
duces the chorea, and that the blood state, instead of being a cause, may 
be a consequence of chorea, the result of tissue metamorphosis due to ex- 
cessive muscular action. 

He raises a question as to the disappearance of the movements, and 
considers this condition of affairs incompatible with organic lesions. This 

iPhila. Med. Times, August 5, 1876. 
2 Op. cit. 



494 CEREBEO-SPINAL DISEASES. 

objection, however, seems to lack force when we remember that in aggra- 
vated cases the movements do not stop during sleep. Another fact is to 
be considered, and this is the tendency to relapse which the simplest cases 
present. 

The embolic theory has been advanced by nearly every investigator, 
and its strongest supporters are Broadbent, Hiighlings Jackson, and Bas- 
tian. The original investigations of Kirkes served as a basis for this new 
theory. He found that particles of fibrine were washed into the cerebral 
vessels. Hughlings Jackson located the place of final deposit in the gray 
matter of the convolutions in the neighborhood which is supplied by 
the middle cerebral artery. Jackson very cogently considers the signifi- 
cance of its one-sided character as compared with hemiplegia from embo- 
lism, and has since brought up the question of involvement of the mus- 
cles more concerned in special voluntary acts, which are likewise conspi- 
cuously affected in certain forms of hemiplegia and epilepsy, with cortical 
degeneration 

Against this theory, some writers have raised the question in regard to 
the existence of the hemichorea on the same side of the body as that of 
the brain where the lesion is found, and contend that there must be 
crossed action. The recent and conclusive investigations of Flechsig al- 
luded to in other parts of this book, show however, that total decussation 
does not take place in the medulla. 

Dupuy and Brown-Sequard have made experiments which prove that 
such a condition of affairs may exist, and I have myself done the same 
thing. Since my experiments, I have heard of a case, related by Dr. 
Walter Hay, of Chicago, in which post-mortem examination revealed a 
cerebral hemorrhage on the side of the hemiplegia. 

In one of these experiments made by Dr. F. H. Rankin and myself 
upon a monkey, electrical irritation (galvanic) of the white matter just 
beneath the cortex of the upper part of the left ascending parietal con- 
volution produced convulsions in both extremities of the same side. 

The views of Jackson now seem to warrant the supposition that in a 
very large number of cases, in those especially in which no post-mortem 
appearances were found ; or at least have not been hitherto looked for in 
the region of the cortical motor centres where they might have existed 
unrecognized ; that the motor area of the cortex is primarily in fault. In 
some cases we are furnished with startling proofs of this. 

A woman who recently died at the Hospital for Epileptics and Para- 
lytics, and who was in my ward for a number of years, presented the 
most aggravated symptoms of chorea I have ever seen. Her disease had 
lasted for twenty or thirty years, and before her death there were decided 
mental disturbances which occasionally burst out in attacks of mania. 
Her whole body seemed to be affected, for every limb was agitated by cho- 
reic twitchings. She sat usually upon a low chair, her body bent for- 
ward, her arms extended, and her fingers spasmodically working. Her 
head was in a constant state of movement, and her lips and facial muscles 
were implicated as well. She could not talk distinctly, but her utter- 



t CHOREA. 495 

ances were explosive and rapid. There never had been any paralysis, 
but after death the important cortical motor centres on both sides were 
found to be the seat of atrophy. In this case, which probably re- 
sembles others of the same class, the destruction of certain psycho- 
motor cortical centres does not result in paralysis, but a loss of 
governing control upon the part of the upper gray matter, while the 
lower motor ganglia act independently and inharmoniously in the inner- 
vation of the muscular system. 

Broadbent localizes the lesions entirely within the corpus striatum. He 
also calls attention to the existence of peripheral irritation, shock, and 
various causes which may produce a depraved functional condition. 

Bastian adopts the theory that the emboli consist of masses of agglome- 
rated white corpuscles, and that the location of the lesion is in the corpus 
striatum. 

Dickinson is disposed to regard the chorea as the result of rheumatism 
rather than of endocarditis, and considers the central condition one of 
hypersemia.of the nervous centres, " not due to any mechanical mischance, 
but produced by causes mainly of two kinds : one a morbid, probably a 
humeral, influence which may affect the nervous centres as it affects other 
organs and tissues ; the other, irritation in some mode, usually mental, 
but sometimes what is called reflex, which especially belongs to and dis- 
turbs the nervous system, and affects persons differently according to the 
inherent mobility of their nature." 

In regard to localization he agrees in the main with the other observ- 
ers. " The spots of perivascular change are widely scattered throughout 
that large region which lies inferiorly to the cerebral convolutions be- 
tween the corpora striata and the lower end of the cord ; the district of 
the motor and sensory as distinguished from the mental functions." 

It seems, then, that the quality of the lesion is only disputed. I am 
strongly inclined to accept the embolic theory, not only because the pare- 
sis of the limb may precede any muscular movements, but because lesions 
in or about the corpora striata, which produce hemiplegia, may also give 
rise to choreic movements, but I believe that the motor zone of the cortex 
is often at first the seat of pathological changes. 

Diagnosis. — The movements of chorea must be differentiated from 
those of sclerosis and paralysis agitans. This will not be a difficult task, 
as the peculiarity of the choreic movement is the Jerk, while the tremor of 
the other affection is rhythmical and usually fine, and varies under certain 
circumstances. The rapid recovery should also be an element in the di- 
agnosis. 

That chorea may result in some secondary disease, such as softening or 
meningitis, is well settled ; and in these cases it will be necessary to take 
into account the character of all the new symptoms, and the history of the 
old ones. 

The exceptional forms of the disease may be mistaken for hysterical 
troubles, and then the diagnosis will be difficult. It must be borne in 
mind, however, that this mistake can be made only in adult cases. The 



496 CEREBRO-SPINAL DISEASES. 

paralysis of chorea may be differentiated from true cerebral or spinal pa- 
ralysis by its gradual development, and by the age of the individual, as 
these two forms are quite rare in infancy. Choreic movements usually 
stop at night, and the exceptions to the rule of quiescence during sleep 
include those in which the patients have " dreams of movement," such as 
were alluded to by Marshall Hall. 

Prognosis. — Chorea is an affection which may very often disappear, 
without any treatment whatever, in from six weeks to four months ; but 
there are very likely to be relapses. If properly treated, the movements 
should disappear in from six weeks to two months, or even in a shorter 
time. If the disease appears after puberty, the prognosis is unfavorable, 
and all we can do in some cases is to moderate its violence. There is 
a tendency to recovery in other cases, among them those of pregnancy. 
Death is a very unusual termination, and it rarely occurs as a result of 
the disease itself, but rather of some cardiac complication. 

Treatment. — Internal remedies : Strychnia ; arsenic ; iron in its 
various forms (bromide, carbonate, etc.) ; phosphorus and cod-liver oil. 
External remedies : Cold to spine — ice, ether spray, and cold douche ; 
Russian or Turkish baths ; and salt baths. Rest, diet, and fresh air. 

Some of these may be combined with good effect. The plan of treat- 
ment I generally employ is the following : Should the child be " run 
down," as is generally the case, I begin with some preparation of iron, 
and administer at the same time cod-liver oil. As regards special treat- 
ment, I find strychnine serviceable, carried up to the point where stiffness 
of the sural muscles is arrived at. Next to this stands arsenic. It 
must be given in large doses ; but when we find that digestive troubles 
are produced very quickly by this drug, strychnia may be substituted. 
In some cases, when gastritis is produced, we may use the arsenic in the 
form of Fowler's solution hypodermically, and larger doses may be ad- 
ministered in this way. Cold to the spine cannot be overestimated as a 
plan of treatment. We may either use the ether spray, which was first 
suggested for use in this disease by Subetski, of Warsaw, in 1866, or 
apply ice-bags every day, allowing them to stay on about ten minutes. 
Perroud, who has used the ether spray, makes applications from four to 
eight minutes in duration every day. Of thirty-five cases I have treated 
in this way (I mean with the ether spray), from fifteen to twenty appli- 
cations produced permanent benefit ; and here I would say that the spray 
should be directed chiefly to the upper part of the cord, over the upper 
cervical vertebrse. Eserine has been recommended, and Bouchut has 
given the results of 437 cases, 205 of whom took it in pilular form, 
and 232 hypodermically. The average dose was from two to five milli- 
grammes. He obtained temporary benefit, which seemed to wear off; 
but when the drug was repeatedly administered, he accomplished many 
cures. He reports twenty-three cures by an average of seven injections. 
It is a dangerous remedy, however, and produces severe gastric symptoms. 

The salts of zinc have occasionally proved valuable in cases of this dis- 
ease ; and conium is occasionally efiicacious, but its effects are tempora- 



CHOREA. 497 

ry ; but I prefer the remedies I have mentioned. I have found phospho- 
rus, with cod-liver oil, to be a most valuable curative agent, and in cases 
where everything else failed it has succeeded. This seems reasonable, 
when we consider how much impaired must be the nutrition of the nerv- 
ous matter. 

Da Costa^ and Mills,^ of Philadelphia, have used the bromide of iron ; 
but the latter has had very successful results. In twelve patients to 
whom he administered the drug, there was no improvement after its use. 

Dr. Mills says : " It was usually given in plain syrup and water, com- 
mencing with five grains three times daily, as recommended, and rapidly 
increasing the dose to twenty. The treatment was continued from two to 
four weeks. Twenty grains very generally caused vomiting. It seems 
to be a remedy which quickly irritates the intestinal tract." 

Oulment and Laurent recommended hyoscyamin in doses of one-six- 
tieth of a grain, in pill form, at first twice daily, and afterwards more 
frequently. Amelioration is said to begin in eight or nine days for a 
child. I have administered hyoscyamin to a number of cases with great 
benefit. It is, however, a most dangerous remedy, and the commencing 
dose should not be more than 2W of a grain, to be increased if dryness of 
the mouth and dizziness are not too great. Should the presence of worms 
be suspected, we may either use an injection of quassia and carbolic acid 
solution (gtt. X — Oj) after each stool, or pursue the ordinary santonine 
treatment. The use of ferruginous tonics is generally indicated, and those 
should be selected which are best assimilated and which tax digestion 
the least. I would therefore recommend either the carbonate of iron, or 
dyalized iron. The addition of digitalis seems to increase their good 
efiects quite materially. Chalybeate waters are useful, and sulphur baths 
are recommended by Baudelocque and others. 

Trousseau recommends morphine and strychnine, but I have never 
seen any good results follow the use of the former; of the virtues of the 
latter I have already spoken. H. C. Wood recommends a tincture made 
from the fresh leaves of the skunk-cabbage, with which he has had some 
success. Electricity I have no faith in, except, perhaps, when the so-called 
" general electrization " is used as a cutaneous and muscular stimulant. 
Benedikt has cured many cases by galvanism; but, as far as I can learn, 
his results are exceptional. 

There are instances where nothing does good. It is well to put the 
patients in a dark room, and keep them perfectly quiet. We will be 
often astonished at the result. There are little things that must be 
watched. The diet, above all things, should be regulated with judgment. 
Plenty of fresh air and sleep come next, and absolute mental rest must 
be enforced. The school-books and the school-room are to be parted from, 
and agreeable diversions planned. An excellent auxiliary to our medi- 
cation is the salt-bath. A handful of rock-salt in the water, and the ener- 

1 Med. and Surg. Eeporter, Jan. 30, 1875. 

2 Phila. Med. Times, Sept. 25, 1875. 
32 



498 CEREBRO-SPINAL DISEASES. 

getic use of the rough towel, will infuse a tone and vigor that will soon 
become apparent. In conclusion, I must say that decided medication is 
useless in these patients if their personal habits are not looked after. 

PAKALYSIS AGITANS. 

Synonyms. — Shaking palsy ; Parkinson's ^ disease ; Trembling palsy ; 
Tremblement senile ; Chorea senile ; Chorea festinans. 

It is unfortunate that so much confusion exists in regard to the proper 
classification of this tremor of old age. It has been and is to this day 
confounded with cerebro-spinal sclerosis. 

I shall speak of it as a disease of advanced life, symptomatized by paresis, 
involving usually the upper extremities, with tremor which is not increased 
by voluntary muscular action. This tremor rarely affects the muscles of 
the face, except in advanced stages of the disease, and is accompanied by 
fesfcination, and in certain cases by bending of the body forwards, and 
inclination of the chin forwards and downwards. 

Symptoms. — The extremities first become the seat of tremor, the fin- 
gers being agitated in the beginning; the hand is next involved, and after- 
ward the arm. This tremor is bilateral, and it may not make further 
advances for some time, but ultimately the head, and other limbs are 
included. The tremor may involve one hand before the other, or the leg 
of the same side may be next affected, then the leg of the other side, and 
next the opposite arm. After a variable time, extending from one to ten 
years, a species of muscular rigidity takes place, so that the head is drawn 
down, and ultimately the body is bent and the head is thrust forwards, or 
the chin is drawn down to the breast. The forearms and hands are flexed, 
and the arms may be drawn to the side of the body. The constant move- 
ments may produce an actual abrasion of the skin by friction of the elbows 
or hands, should the muscular contraction bring them in contact with the 
body. Any attempt at locomotion is attended by what has been called 
" festination." The patient may rise slowly from his seat, and perhaps 
in the early stages walk, slowly though awkwardly, by taking long strides, 
but>hen the muscles of the back lose their power, and the body pitches 
forward, the patient's attempts to preserve his equilibrium result in a 
shufiling gait, and finally he is compelled to run and gladly clutches the 
nearest chair or support to avoid falling. 

The voice is weak and the speech broken and abrupt, and the form of 
interruption has been compared by Charcot "to that which affects a novice 
in equitation when his horse begins to trot." This interruption is caused 
by the violence of the muscular movements. The patient pitches his 
voice when he begins to speak, and never changes the tone until he has 
finished, so that his phonation is decidedly monotonous. He is greatly 
fatigued by the constant muscular movements, and is restless and inclined 
to seek new positions which may give him ease. A disagreeable symptom 
is the occurrence of cramps of temporary duration, which are more com- 

^ Essay on Shaking Palsy, London, 1817. 



PARALYSIS AGITANS. 499 

mon during the day. During the tremor the fingers or toes may be 
rigidly flexed or extended. The face is utterly devoid of expression, but 
the mind is never impaired, and there are no affections of the organs of 
special sense. The tremor in the beginning ceases at night, but in the 
established form it is present at all times. 

The termination of the disease may be in death through exhaustion or 
complicating diseases, such as pneumonia, which carried off three cases 
reported by Trousseau. The functions of the bladder and rectum are not 
usually involved, except when the disease has become confirmed. In one 
case Topinard found sugar in the urine, but it is hardly necessary to say 
that this circumstance is exceptional. 

After suffering for a number of years the patient is finally obliged to 
seek his bed, sloughs form over the sacrum, and he gradually sinks, the 
tremor, perhaps, moderating slightly before death. 

The following interesting case is one that illustrates the course of the 
disease perfectly : — 

Mr. M., the patient, during his early years led an active life, and after 
following the occupation of a peddler gradually worked his way up to 
prosperity. For years he went about the streets of New York carrying, 
many hours in the day, a heavy pack upon his back, and during this time 
he suffered many privations of food, rest, and sleep, and was exposed to 
the elements, after going home wet and cold. About fifteen years ago he 
first noticed the appearance of his present disease. He is a stout man of 
large frame, and about 70 years old. The trembling began after slight 
exertion, and continued for some time. It became more pronounced and 
constant during the next two or three years, and he was unable to un- 
button his clothing, feed himself, or use his hands. His general health 
did not seemingly suffer, but he was "nervous" and depressed, and fully 
aware of his pitiable state. He did not tremble so much when lying down, 
but when he moved about or assumed the erect position the hands shook 
and the head shook constantly from side to side. The movements always 
stopped at night, but it was some time before he could sleep. He gradu- 
ally lost power; the right arm losing strength primarily, and afterwards 
the left. Coincident with the loss of power there was tremor. When I 
saw him two years ago, I found him seated in a chair in which he had 
difficulty in keeping his place. His upper extremities and head were 
chiefly affected. The head was inclined forwards, and was constantly 
agitated by movements of a rhythmical character, which did not appear to 
be increased or diminished by any act of volition. He could not raise his 
chin, but looked up at me when I entered the room with his son. When 
asked a question, he answered in a tremulous voice, speaking as would one 
who was chilled. His body was curved forwards, and his arms were semi- 
flexed, the elbows being drawn to the chest; and forcible or voluntary 
extension was impossible. There was no atrophy of the muscles of the 
arms or forearms, and no decided loss of sensation. The hands were agi- 
tated by the same rhythmical tremors as the head. When he was lifted up 
he could not walk, and would have pitched forward if not held. In this 
position I noticed that the knees were also affected by the tremor. His 
bladder and rectum did not seem to be involved, at least not as a result 
of the disease, for beyond symptoms of enlarged prostate he suffered no 
impairment of function. For the past two years he has needed powerful 



500 CEREBEO-SPINAL DISEASES. 

opiates to procure sleep, the movements continuing unless they are given. 
He swallows with difficulty, and there is a drain of saliva from the corner 
of his mouth. As far as I can learn there have been no disorders of the 
organs of special sense, and certainly there are now none. His mind 
seems to be somewhat affected, as he is irritable and silly, and his memory 
is deficient. 

It may be stated that the affection may exist in a modified form (Par- 
kinson's disease) and that tremor alone may be the only symptom. 
Festination and rigidity are by no means constant expressions of the 
affection. 

Causes — Nothing is known in regard to the causes of paralysis agi- 
tans. It has followed mental distress, or has been preceded by neuralgia 
and rheumatism, but these seem to be connected with so many nervous 
diseases that it is difficult to say just how much they have to dowdth the 
etiology of paralysis agitans. I have seen several cases, and in none of 
them was there any history of predisposing or exciting causes. We know 
that the disease is rare before the fortieth year, and that the male sex is 
more often affected than the other sex. 

Morbid Anatomy and Pathology. — Handheld Jones ^ holds 
to the doctrine that the affection is purely of a functional character while 
others believe it to be a multiple cerebral sclerosis. In an excellent re- 
view of the recent writings of Charcot and Moxon, which has appeared 
lately, the reviewer says : " There is a certain satiric humor in Professor 
Charcot's notice of the morbid anatomy of paralysis agitans. He divides 
the autopsies hitherto made into three groups. In the first group nothing 
at all was found. The second group comprises cases of supposed paraly- 
sis agitans, which Prof. Charcot considers were in reality sclerosis ; and 
the third group contains the case of Parkinson subsequently mentioned, 
and a similar case by Oppolzer, which is treated with similar distrust. 
There are, however, other cases on record which give much more satis- 
factory results. Leyden has reported one in which the agitation was 
limited to the right arm, and a sarcoma the size of a large nut was found 
in the optic thalamus of the opposite side. Murchison and Cayley have 
reported a case in which very definite changes, partly of sclerosis and 
partly of cell growth, were found in the cord ; but as in this case the 
symptoms are described but very briefly, it is possible that Prof. Charcot 
would place it in his second group. Joffroy, however, took especial care 
to investigate this point, as to whether the cases were really paralysis 
agitans or insular sclerosis, and he states that two out of his three cases 
were clearly paralysis agitans. In these two cases there was exuberant 
growth of the epithelium of the central canal and of the nuclei around. 
In the third case, which seems not to have been a very doubtful one, there 
was in addition a sclerosed patch in the medulla."^ 

The pathology of tremor is still so imperfectly understood, and there is 

1 Functional Nervous Diseases, p. 382. 

'^ Brit, and For, Med-Chir. Kev., Oct. 1875. 



PARALYSIS AGITANS. 501 

SO much to be said, that it would involve a much more protracted consi- 
deration than the size of this book will permit. We may, however, con- 
sider some 0|f the physiological conditions of muscles which, when dis- 
turbed, result in the pathological state known as tremor. 

The variation or interruption of any compound entity is followed by 
an inharmonious relation of its parts ; thus a musical sound is the result 
of a number of more or less rapid vibrations and waves, their number 
influencing pitch. If a catgut string in a state of tension is twanged, 
vibrations are induced and a musical tone is produced ; but if a stick be 
loosely held against the string, without actual pressure being made, the 
vibrations will be interrupted, and a discordant noise will be the result 
of such contact. It has been demonstrated that a visible muscular con- 
traction is, after all, the result of an incredible number of smaller con- 
tractions, which cannot be seen with the naked eye, but may easily be 
appreciated with the aid of the myographium or some other registering 
instrument. Upon faradizing a muscle this may be experimentally de- 
monstrated. Shorts breaks are followed by visible contractions of the 
muscle and movements of the limb ; but if by a proper current-breaker 
this interruption be repeated many hundred times a minute, the intervals 
will be so short that, though an immense number of rapid contractions 
take place, there is but one grand contraction of the muscle which is ap- 
preciable. 

In the physiological state this co-ordination (if I may use the word) of 
the minor contractions is so perfect that the muscular movements are 
steady and separated by regular intervals ; but when the rhythm is lost, 
or the harmony destroyed, the smaller contractions will be separated by 
intervals of sufficient length to be seen, and tremor results, the degree of 
tremor being proportionate to the length of the interval. 

The filaments of a tired muscle, the motor centres being worn out, do 
not contract evenly ; so, as a consequence, there is a visible tremulous- 
ness. In functional tremor, such as characterizes the disease in question, 
this is undoubtedly the pathological condition. 

Diagnosis. — The treatment of cerebro-spinal sclerosis may be mis- 
taken for that of paralysis agitans. Let us compare the points of dif- 
ference : — 

PARALYSIS AQITANS. CEREBRO-SPINAL SCLEROSIS. 

Tremor continues, but not increased by Tremor subsides during repose, and is 
voluntary efforts. always aggravated by volitional attempts 

at control. 
Tremor regular and '' fine.'' Tremor '' coarse.'' 

Facial muscles unaffected. Usually cranial nerve paralysis, or tre- 

mor of facial muscles. 
Runs forward to preserve balance. Only staggers when walking is at- 

tempted. 
Speech slow, or affected by violence of Speech-defects those which arise from 
muscular movements. paralysis. 

A disease of old age, or advanced Usually a disease which appears before 
life. middle age. 



502 CEREBRO-SPINAL DISEASES. 

Mercurial tremor, lead tremor, and alcoholic tremor sometimes resem- 
ble that of the disease in question ; the former is, however, more violent 
in the morning ; the tremor from lead is attended usually by colic and 
other symptoms of plumbism ; while no doubt need arise in regard to the 
third, which is attended by evidences of alcoholism. Post-paralytic cho- 
rea may be excluded by the history of hemiplegia or some other equally 
prominent organic condition, and the tremor is aggravated by voluntary 
efforts. A functional tremor of a very light grade, which is simply a 
personal peculiarity, is met with sometimes, and should not be magnified 
to the dignity of a disease. This may affect several members of the same 
family, as is the case in one example of which I know. The head of the 
family is a vestryman of a church, and in passing the plate he sometimes 
is obliged to exercise the utmost self-control to prevent the contents from 
being thrown out, and more than once this infirmity has given rise to in- 
sinuations concerning his habits. His two children, both very young and 
healthy people, are affected by the same tremor. In such a case the trou- 
ble does not increase with time, and there are none of the other progres- 
sive signs of the true affection. 

Prognosis. — The course of paralysis agitans is decidedly progressive, 
though very gradual, and the individual may live for ten, twenty, or even 
thirty years after the appearance of the tremor. When death takes place, 
it is in nine cases out of ten the result of some other disease. I am con- 
vinced that genuine paralysis agitans is never cured, though it may be 
relieved ; and it is highly important to distinguish simple functional tremor, 
which is not uncommon, from the disease under consideration. This func- 
tional disorder is amenable to treatment. 

Treatment. — Handfield Jones ^ considers that nothing can be done 
for the disease among very old people when it has become decidedly 
chronic. He has used electricity, conium, and a variety of remedies. 
'* The general tenor of experience in this and in kindred disorders is to 
the effect : (1) that the main indication is to nourish and support the fail- 
ing power of the nervous centres affected ; (2) that this is best accom- 
plished by remedies drawn from the class of sedatives, or by the milder 
tonics. Henbane, conium, chloral, subcutaneous opiates, bromide of po- 
tassium, belladonna, hypophosphites, or phosphorus, cod-liver oil, carbon- 
ate of iron, and sulphuret of potassium baths, with electricity in one or 
other of its three forms, appear to me the most hopeful remedies. But 
steady persistence in appropriate treatment is doubtless essential, and the 
want of this may account for many failures. Trousseau's adage should be 
borne in mind, * A longue maladie, longue traitement.' " 

He refers to a cure reported by another observer. The patient was a 
woman, eighty years old, in whom the disease followed severe labor; and 
she was ultimately unable to carry trays or heavy loads. The faradic cur- 
rent used several times effected the disappearance of the tremor. I am 



1 Brit. Med. Journal, March 8, 1873. 



EXOPHTHALMIC GOITRE. 503 

inclined, however, to consider this case one of functional tremor, and not 
of the grave variety I have described. 

I have used conium with good results, and find that it relieves the pa- 
tient, but after the use of the drug has been discontinued for a few weeks, 
the tremor is pretty sure to reappear. It should be given in doses of the 
fluid extract of from rri v-»n. viij thrice daily. 

Hyoscyamin, a remedy that possesses virtues second to none as a de- 
presso-motor, is worthy of a trial in this affection, although in chronic 
cases its good effects are rarely more than temporary. 

Elliotson^ has cured a case by the carbonate of iron in large doses, and 
strychnine has been suggested, but it is doubtful whether it does any real 
good. 

Galvanization of the spine, one pole placed over the spine, and the 
other as near as possible to the point of exit of the spinal nerves, has been 
advised ; and in some instances it has improved, if it has not cured, the 
affection. 

EXOPHTHALMIC GOITRE. 

Synonyms. — Basedow's disease; Graves' disease; Exophthalmic 
cachectique; Cardiogmus strumosus. 

This interesting disease has received but little attention until within a 
few years, and it is only lately that it has been considered as a neurosis. 

Definition.^— Exophthalmic goitre is a disease connected with vascu- 
lar excitement and circulatory disturbance ,\ there is not only enlargement 
of the thyroid gland, but an excessive engorgement of the intra-orbital 
vessels, so that the eyeballs are pressed forward, giving rise to a hideous 
deformity. 

Symptoms. — The first symptoms of the disease are generally indi- 
cated by violent action of the heart, and great acceleration in the circu- 
lation; and with this there is hypersemia of the cerebral vessels. Pal- 
pitation and pain over the left side of the chest, shortness of breath, and 
flushing of the face are other symptoms of this early stage. This early 
vascular disturbance is, perhaps, the first evidence of the disease noticed 
by the patient, but the enlargement of the thyroid gland may have been 
progressing for some time. There may be other early symptoms which 
appear with increased growth of the goitre, and protrusion of the eye- 
balls. These are falling out of the hair of the eyebrows, as well as the 
eyelashes. 

The heart's action is violent throughout the disease, and the pulse may 
beat from 120 to 140 per minute ; while the temperature is one or two 
degrees higher than the normal standard. There is nearly always a sys- 
tolic bruit and a carotid murmur. The hand, when placed over the 
goitre, may receive a peculiar sensation, which is produced by the agi- 
tation of the thyroid by the rapidly circulating blood in the enlarged 
vessels. 

^ Quoted by Jaccoud, op.cit., vol, i., p. 427. 



504 CEREBRO-SPINAL DISEASES. 

Although the disease begins suddenly in some instances, it is usually of 
slow development, and, according to Eulenburg, there may be hysterical 
manifestations before the pulse acceleration manifests itself. I have my- 
self noticed that the patients then seen were emotional and easily excited. 

Digestion is nearly always impaired, and there may he some diarrhoea 
or attacks of vomiting ; while sleep is troubled, and the patient suffers 
greatly for want of rest. His appearance is unmistakable. One or both 
eyes are prominent, and uncovered by the lids ; and the sclerotic is ex- 
posed above the cornea to a great extent. The patient is hypermetropic, 
and suffers considerably from conjunctivitis produced by the irritation of 
foreign bodies which lodge there. 

There is rarely any visual disturbance, although troubles of accom- 
modation are met with ; and there are no changes to be observed in the 
retina. 

Dr. Yeo reports two very valuable cases, which are presented in admi- 
rable shape in a late number of the British Medical Journal} In one 
of these there was exophthalmos of the left eye only, the goitre 
being on the right side. The second case was thus described by Dr. 
Yeo : " The patient is a young single woman, 23 years of age, robust and 
strong-looking. She shows no signs of the pronounced cachexia (phthisi- 
cal) so evident in the other patient. But she is especially interesting 
now, as being also the subject of unilateral exophthalmos. In her case 
the right eye only is prominent. There is very little, if any, enlargement 
of the thyroid, but there is constant palpitation. The pulse has varied 
during the time she has been under observation from 116 to 140. She 
comes of a healthy family, and has always had good health till lately. 
She first noticed the prominence of the right eye about a year ago. All 
this time she has been feeling nervous and excitable. She came to King's 
College Hospital about nine months ago complaining of pains in the back 
of the head and palpitation. She stated, also, that she suffered frequently 
from ' bilious attacks,' attacks of vomiting which would last a whole day, 
after which her throat would get very large. She complained, also, of 
frequent profuse perspirations coming on twice and three times a day, 
sometimes without any cause and sometimes on the slightest exertion. 
The hands and feet are always perspiring, and her hair is sometimes 
wringing wet." She is easily fatigued, has lost her appetite, and is much 
thinner than she used to be. She suffers much from dysmenorrhoea, and 
all her symptoms are worse at her periods. She says her throat was much 
more enlarged nine months ago than it is now. 

There may be double exophthalmos or single, but the double affection 
of the eyes is the rule in the great proportion of cases. In some cases it 
is absent entirely, and of 58 cases reported by Von Dusch it was absent 
in four. 

The eyeball may be pressed back, as the vascular cushion behind is 



1 March 17, 1877. 



EXOPHTHALMIC GOITRE. 



505 



soft and yielding; and a peculiar thrill is felt. An " arcus senilis" 
has repeatedly been observed by Bartholow/ who first called attention 
to this change, and by others afterward, among them Thomas.'' Von 
Graefe was the first to allude to the peculiar behavior of the upper lid, 




Dr. Yeo's Case of Exophthalmic Goitre. 

which, as Eulenburg expresses it, " loses its power to move in harmony 
with the eyeball in the act of looking up or down." Irritability of tem- 
per, hysteria, laryngeal trouble, and difficulty of breathing are symptoms 
which are to be noticed, and towards the end this respiratory embarrass- 
ment becomes quite distressing. 

The patient is generally badly nourished, and we may have added to 
the symptoms already described, many of those of general anaemia. 

The skin of the whole body may sometimes be of a much darker hue 
than it is in a condition of health, and some discoloration of that covering 



^ Chicago Journal of Nervous and Mental Diseases, July, 1875. 
"^ Eichmond and Louisville Med. Journ., Nov. 1876. 



^06 CEREBRO-SPINAL DISEASES. 

the forehead is often noticed. This discoloration resembles a brown stain, 
and it has been spoken of as " bronze skin " by some writers. Eaynaud^ 
has called attention to the connection between this stain, or vitiligo, and 
exophthalmic goitre. He gives " five cases of exophthalmic goitre, culled 
from various sources, in the course of which patches of vitiligo appeared 
on various parts of the body. Beyond the observation that vitiligo is 
more common in men than in women, except when congenital, that it 
attacks by preference persons of dark complexion, that it is sometimes, 
though rarely, hereditary, and has a certain analogy to Addison's disease, 
viewed as an imperfect vitiligo, little has been made out with regard to 
its pathology. Mr. Hutchinson has pointed out that although no known 
cachexia appears to set up a predisposition to the affection, the symmetry 
of the cutaneous patches is suggestive of some pre-existing general fault 
of the circulatory or nervous systems, and is opposed to the hypothesis of 
a parasitic origin. Without offering any explanation of the coexistence 
of vitiligo with exophthalmic goitre, Dr. Kaynaud thinks that the coinci- 
dence should not be allowed to pass unnoticed." 

The connection of urticaria has been pointed out by Bulkley, who 
reports two cases of the disease. One of these is presented : — 

" Mrs. — , aged 45, was delicate and sickly when a child. Was married 
at 18 years of age, but separated from her husband after 4 months ; she 
had a miscarriage at 3 months, and has never been completely well since. 
She is of full habit; bowels and menses regular; tongue coated; pulse 
84, weak ; has had chronic rheumatism. 

" The history of the Graves' disease dates back a number of years — at 
least five years previous to my seeing her. This diagnosis was made by 
a prominent oculist whom she consulted about the projection of her left 
eye. She has been treated much of the time ineffectually by various 
physicians, remaining with each long enough only to experience more or 
less benefit, and then changing. The eyes exhibit clearly the peculiar 
appearance of patients with exophthalmic goitre, the left one being more, 
strikingly prominent, and being of but little service for vision, she soon 
losing control of it. The other phenomena of the disease have been present 
for some years — irregularity of the heart's action, and at times severe 
palpitation, and enlargement of the thyroid ; but this is not so very 
marked. 

" Five years before coming to me she experienced a severe nervous 
shock, and dates her skin trouble from that period. She states that she 
has not perspired since. She began then to have ' a fine rash and redness 
all over the body,' and itching. This continued about the same, off and 
on, for four years, when, after being weak and exhausted, and having 
various hysterical diflSculties, the itching became more general, and an 
eruption corresponding to that now existing appeared. Lumps would 
form on the forehead and on various parts of the body ; sometimes the 
face and head would appear greatly swollen. 

" When first seen she was in a pitiable state of nervous anxiety ; the 
itching of the feet and toes and sometimes of other parts of the body she 

1 Archives Gen., June, 1875; and London Med. Record, Sept. 15, 1875. 



EXOPHTHALMIC GOITRE. 507 

described as agony. At the first visit there was not so much to be seen 
on the skin, but there were a few urticarial blotches on various parts of 
the body and limbs. While under observation, however, she had several 
acute attacks of skin trouble, all of the same sort. On one occasion she 
woke with the upper lip greatly swollen, and with swellings on various 
parts of the body. On the following day, when seen, the whole face was 
swollen and puffy ; on the middle of the forehead there was a large erythe- 
matous lump, also one beneath the right eye, and smaller ones about the 
face. The hands were swollen ; on the right hand, near the little finger, 
there was an erythematous patch, somewhat swollen and with two small 
vesicles on it. There were also various erythematous and urticarial 
blotches about both hands and wrists ; and on the back of the left hand, 
near the thumb, there was a red spot with the skin broken, as if the seat 
of a former vesicle. The whole surface cf the skin burned as if scalded 
or scratched ; there was no pain on deep pressure. On another occasion, 
a day or two after there had been, according to her statement, numerous 
swellings on various parts of the body, the remains of several were visible 
on the right cheek, and on the arms there were numerous stains, some of 
them quite dark, as if the parts had been bruised — the remains of the 
lumps ; the hands and arms were manifestly swollen, and there were 
urticarial wheals on the limbs and body." 

The following case is one of unilateral thyroid enlargement, with double 
exophthalmos : — 

Mrs. L. B., 28, U. S. ; milliner. Was always well until eight years 
ago, when her present difficulty began. She was them living in New 
York, and actively employed. At this time she noticed the growth of a 
goitre upon the right side of the neck, which pulsated violently when she 
was excited or over-fatigued. She then flushed easily, and often had 
headaches, which were quite intense. These she has now, and her pain 
is of the congestive variety, and diff'used. She presented herself at the 
out-patient department of the New York Hospital, complaining of a pain 
just beneath the border of the last rib on the left side, which was quite 
constant, but not increased by pressure, or by taking a long breath, or after 
eating. The pain was most severe in the morning, and seemed to move 
off" towards night. Her heart seemed healthy, so far as valvular lesions 
were concerned, for no abnormal murmur was present ; but there was 
great rapidity of action, the pulse-beats varying from lOB-120 per minute. 
The pulse was also quite bounding, and full. The carotids pulsated quite 
strongly, and there was a very marked venous thrill perceptible in the 
jugulars. Upon the right side of the neck, just above the sterno-clavicu- 
lar articulation, and extending laterally, there was a tumor measuring 
2? inches in length, and about 2 inches in breadth. The marked pulsa- 
tion of this growth led Dr. Slaughter and myself to suppose at first that 
it was an aneurism, but we were unable, to reduce it by pressure, or to 
diminish its size by compression of the carotid ; and there was no history 
of injury. The peculiar movement was due to the pulsation of the carotid 
upon which it rested above, and laterally passed the right jugular vein, 
which was also agitated by the transmitted pulsation of the carotid. 
When the hand was placed upon the enlargement there was perceived an 
undulatory or " purring " movement. No bruit was heard with the stetho- 
scope, but the tracheal sound was readily perceived. This growth under- 



508 CEEEBRO-SPINAL DISEASES. 

went variation in its size. Cold weather seemed to influence it in this 
way, and stimulants, or other agencies which increased the blood pressure, 
materially modified its size. The face was puffed, bloated, and red, and 
the eyeballs were somewhat prominent, while the pupils were dilated, and 
the irides rather sluggish. She was not hypermetropic, and there were no 
other defects noticed. By steady pressure I was enabled to perceive the 
" cushion feeling" alluded to by medical writers who have observed this 
disease. Her companions twitted her in regard to her fixed stare, which 
resulted from the exophthalmos. Her ankles and feet were oedematous, 
and pitted deeply on pressure. Her urinary organs seemed to be in order, 
and there were no indications of renal disease. She has noticed at times 
patches of rusty discoloration which appeared about her neck and upon 
the left side of her face. These lasted for several days, and then faded 
away. She has had several minor symptoms, such as nose-bleed, which 
occurs even now, every two or three weeks. Her menses are scant, but 
there is apparently no uterine disease. Her digestion is feeble, and she is 
slightly constipated. R. — Ext. ergotsG fl. 5jj t. i. d. 

Causes. — The disease is one of adult life, and there are about twice 
as many females as males affected. But few cases have been reported in 
which the disease appeared before puberty. Devol saw a case, the pa- 
tient being a girl of two and one-half years. It is connected, in some 
cases, with metrorrhagia, or hsemorrhoidal bleeding, or in others with 
heart disease; but though many authors consider anaemia to be an im- 
portant cause, others are doubtful. 

Examples of traumatic origin have been noted by Begbie^ and Von 
Graefe,^ and others have been apparently of idiopathic origin. The case 
of the first followed injury to the occiput. 

Morbid Anatomy and Pathology. — The observations of those 
who have made autopsies, differ greatly. Morel Mackenzie found soften- 
ing of the corpora quadrigemina and the posterior part of the medulla. 
The heart was not much affected, there being only slight atheromatous 
deposits on the mitral and aortic valves, with thinness. Other observers 
have found hypertrophy of the heart and insufficiency of its valves, but 
in other cases there were no heart lesions whatever. The thyroid gland 
has been found to contain enlarged vessels, and the orbits an increased 
quantity of fatty tissue. In one of Begbie's cases there was sinking of the 
eyeballs in the orbital cavities after death. 

Much discussion has taken place in regard to the pathology of the af- 
fection, but recent investigations point to the nervous origin of the dis- 
ease. The cervical sympathetic has been found to be altered, and numer- 
ous instances of the change have been brought forward by Recklinghausen/ 
Trousseau,* Archibald,^ and others. In eight cases of exophthalmic goitre, 
referred to by Arnozan,^ there was degeneration of the cervical sympa- 

^ Edinburgh Med. Journal, February, 1849. 

2 Archiv. fiir Ophthal,, 1857. 

3 Deutsche KHnik, 1863. 

* Trousseau and Peter, Gaz. Hebdom., 1864. 

5 Med. Times and Gaz.. 1865. e Op. cit. 



EXOPHTHALMIC GOITRE. 509 

thetic ill all ; but in four other cases no such lesion was discoverable. 
In ^ Ebstein's case, as well as those of ^ Reith and Knight,^ the sympa- 
thetic was involved alone, and more often on both sides. Notwithstanding 
this explanation (the sympathetic origin), others contend that it is a dis- 
ease of the brain ; and still another theory is accepted by those who con- 
sider it a cardiac disease per se. The nervous origin seems to me to be 
that which is most acceptable. Not only does the use of galvanic treat- 
ment, which cures the disease, suggest the neurotic character of the affec- 
tion, but the hysterical phenomena mentioned by Basedow, and noticed 
frequently by others, are certainly significant. 

We may, I think, consider the disease to be dependent upon an affec- 
tion of both the sympathetic and spinal accessory nerves. The condition 
of the vessels of the thyroid gland and those of the orbit, the flushing of 
the face, and general disturbance of digestion, are probably due to the al- 
tered function of the first-mentioned nerve, and the heart excitement is a 
consequence of deficient innervation of the accessories. 

Diagnosis. — There need be no mistake made in the diagnosis of this 
affection from simple goitre, and after this is accomplished there is 
nothing else suggested. An inspection of the enlarged thyroid, and 
the protruding eyeballs, and the detection of the vascular excitement, 
are sufficient to enable us to say that the case is one of exophthalmic 
goitre. 

Prognosis. — A cure is recorded by Cheadle,* another by Mackenzie, 
who also reported a death. Bartholow ^ has cured three patients ; Dr. J. 
P. Thomas,^ of Kentucky details a very interesting case which ended 
fatally in five years. Very little can be said in regard to the character 
of the disease, but it his been cured in certain instances in a year or two. 
It may last for several years, however, and is essentially a chronic affec- 
tion. Trousseau, Charcot, and Corlieu^ report cures, in which pregnancy, 
uterine hemorrhage, or some such complications occurred during the dis- 
ease, influencing its disappearance. Of course, the existence of organic 
cardiac disease gives the affection a very serious character. 

Treatment. — Galvanism, it seems, has succeeded admirably, and Bar- 
tholow has cured three cases by this agent. 'Eulenburg treated exoph- 
thalmic goitre, as early as 1867, very successfully, and Meyer and Chvostek 
obtained the most happy results. Eulenburg recommends very mild gal- 
vanic currents, and he uses from 6-8 elements. I have used the current 
from 10-15 Leclanche cells, the water column being employed to regu- 
late, the same. 



^ Quoted by Eulenburg, 

^ Medical Times and Gazette, Nov. 11, 1865. 

" Boston Med. and Surgical Journal, April 19, 1868. 

* St. George's Hospital Reports, vol. iv., 1869. 

^ Richmond and Louisville Med. Journal, 1877. 

^ Rep. by Jaccoud, vol. i., p. 672, 2d edition. 

"^ Cyclopaedia of Practical Medicine, vol. xiv., p. 102, Am. trans. 



510 CEREBRO-SPINAL DISEASES. 

Roth ^ reports a case of exophthalmic goitre, the patient being a woman 
fifty years of age, her menopause having taken place six years before. 
She became debilitated, suffered from palpitation and sweating at night, 
and afterwards there was gradual enlargement of the thyroid gland and 
protrusion of the eyeballs. The pulse was 120, and the temperature 
normal. It was impossible for her to close her eyelids. The exophthal- 
mos was greater on the left side, and the thyroid was more enlarged on 
the opposite side. 

Galvanism was used, the positive pole being placed on the upper part 
of the sternum and the negative on the superior cervical ganglion. On 
the right side ten cells produced no sensation, but on the left, six were 
sufficient to produce burning. The current was also passed through the 
back. The night-sweats and palpitation diminished, and she grew stronger. 
At the end of a month she had gained two pounds in weight, but the 
reduction in size only occurred in the left exophthalmos and left portion 
of the thyroid. 

Chalybeate preparations, digitalis, ergot, and cod-liver oil are all excel- 
lent remedies. Since the appearance of the first edition of this book I 
have cured one case by ergot, and greatly helped another by the con- 
tinued administration of the Syrup of hydroiodic acid in doses 5i«-§ss 
thrice daily. If galvanism be used, we should bring the sympathetic 
nerve under its influence by placing one pole (the positive) at the angle 
of the lower jaw, and apply the negative over the epigastrium or the 
thyroid. 

1 Wien. Med. Presse, 1875, No. 30. 



NEURALGIA. 511 



CHAPTEE XVI. 

DISEASES OF THE PERIPHERAL NERVES. 
NEURALGIA. 

Synonyms. — -(See special varieties.) 

Definition. — Neuralgia may be defined as " a disease of the nervous 
system, manifesting itself by pains which in the majority of cases are 
unilateral, and which appear to follow accurately the course of particular 
nerves, and ramify sometimes into a few, sometimes into all, the terminal 
branches of those nerves."^ 

Neuralgia is essentially the result of lowered vitality, and is never a 
consequence of any sthenic condition. This is proved by the circum- 
stances under which it occurs ; it taking its origin from general debility, 
rheumatism, syphillis, or malaria, or some other disease which produces 
a cachexia. Anstie very justly considers that it is the first expression of 
a condition which later on becomes paralysis — one being a partial dis- 
turbance, or cutting off of the nervous supply ; and the other a complete 
interruption of the nervous force ; and it is a familiar fact that neuralgia 
very often precedes loss of power in parts isupplied by an affected nerve. 

Neuralgia is, then, a disease in which pain is the prominent symptom, 
and with which circulatory, trophic, and motorial disturbances may be 
connected. 

Pain. — Neuralgic pain is quite distinct from that of any other disease. 
It is not at all like that of neuritis, which is constant and aggravated by 
pressure, but it is paroxysmal, and is characterized by a stage of increas- 
ing intensity and rapid recurrence, and by a second stage of " wearing 
out " or subsidence. It appears suddenly, disappears, and returns, being 
broken by a period of rest. These breaks or intervals of remission 
become shorter as the attack increases in severity, until the pain seems 
almost continuous. When the climax is reached, the intervals grow in 
length, and the pain diminishes in severity, and finally subsides. Re- 
peated neuralgic attacks leave the nerve in a hyper aesthetic condition, so 
that at particular points it is tender and sensitive to pressure. 

These foci of exalted sensation have been called by Valleix- '^les points 
douleureux," and correspond to the points of emergence of the nerve 
from its foramen, or at a point when it passes from a deep to a superficial 
course. The terminal ends of nerves are much more often the seat of this 
tenderness than any other part. The external ramifications of the supra- 
orbital branch of the fifth or the small filaments of other nerves— the 

1 Anstie, Neuralgia, etc., p. 14. - Traite des Nevralgies, Paris, 1841. 



512 DISEASES OF THE PERIPHERAL NERVES. 

ulnar and radial for instance — are not rp.rely painful to pressure. These 
painful points are met with frequently in cases of facial neuralgia. A 
gentleman who consulted me some time ago presented this indication of 
facial neuralgia, there being several hypersesthetic spots in the roof of his 
mouth, and his gums on one side were exquisitely tender. 

Circulatory disturbances, of a quite marked character, are pronounced 
features of the neuralgic attack. The pulse at first is irritable, small and 
quite rapid. A species of fluttering palpitation is also present, and the 
surface is pale and cool. In the later stages of the attack, after the pain 
has grown decided, the face becomes flushed; the pulse soft, full, and 
quite bounding ; and the eyes may be suff'used and bloodshot, should the 
attack be one of facial neuralgia. 

During this stage, and after the subsidence of the pain, the patient 
may sweat profusely. 

Trophic Disturbances. — These may be connected with the acute pa- 
roxsyms, or may result from repeated attacks. Among the former may be 
pemphigus, and herpetic and bullous eruptions ; and among the latter, loss 
of teeth or hair, or alteration in the coloring matter of the hair, atrophy 
of muscular tissue, and various cutaneous changes. Charcot and Weir 
Mitchell, as well as various writers upon dermatology, have called at- 
tention to the connection of aggravated neuralgic pain, with various 
cutaneous diseases. The most striking of these neurotic skin diseases is 
herpes zoster, in which eruptions of a vesicular character, a cluster 
of patches are found here and there along the course of the affected 
nerve. The pain precedes the appearance of the eruption, and may con- 
tinue during its existence, and for some time after, or there may remain 
a pruritus, limited to the parts which have been the seat of eruption. 
The neurotic character of this complication may be proved by its very 
rapid disappearance after galvanization of the affected nerves, or admin- 
istration of large doses of quinine.^ The other trophic alterations, which 
are secondary, will be considered at a later period. 

Motility. — Connected with some forms of neuralgia are certain condi- 
tions of spasm. In form of facial neuralgia which has been known 
as tic epileptiform or tic douloureux, tonic spasm of the eyelid or of the 
masseter muscles is present as a decided symptom. Convulsive move- 
ments of the legs, due to spasms of the flexors, have also been observed 
in sciatica by Anstie ; but in cases in which I have noticed this symptom, 
it seemed rather a result of excessive pain, and an effort upon the part of 
the patient to relax the pressure upon the affected nerve. Local spasms 
are quite common ; and the muscles of the face, of the trunk or limbs, 
and the vomiting of sick headache, are varieties of spasmodic action 
which may be cited as examples of this kind. In a case lately under 
treatment, I have been reminded of a condition which I have several 
times observed — a species of heart pain resembling that of angina pec- 

1 A form of skin disease lately denominated pompholyx by Dr. A. E. Kobinson, of 
New York, is an example of a neurosis of this kind. 



NEURALGIA. 613 

toris, and connected with facial neuralgia. With this pain there would 
be spasmodic contraction of the muscles of the thorax. Mitchell ^ " has 
encountered from time to time certain forms of neuralgia, accompanied 
by muscular spasms and extravasations of blood in the affected part. He 
relates three cases, all occurring in females, and explains the circum- 
scribed hemorrhages by nutritive changes in the walls of the vessels, 
occasioned by conditions of the nervous system analogous to atrophic 
changes in the skin and nails in nervous diseases." 

Valleix has divided the neuralgias into the superficial and the visceral, 
and classifies them as follows : — 

A. Superficial. 

1. Neuralgia of the fifth nerve (trifacial or trigeminal neuralgia) 

2. Cervico-occipital. 

3. Cervico-brachial. 

4. Intercostal. 

5. Lumbo-abdominaL 

6. Crural. 

7. Sciatica. 

B. Visceral, 

1. Uterine or ovarian neuralgia. 

2. Neuralgia of the urethra. 

3. " " bladder. 

4. " " rectum. 

5. " " testis. 

6. Hepatic neuralgia. 

7. Neuralgia of the heart. 

8. " " stomach. 

9. Laryngeal and pharyngeal neuralgia. 

Among the first group the most important is neuralgia of the fifth nerve^ 
which may also exist with a motor complication, as tic epileptiform^ or with 
gastric complications, as migraine or " sick headache." 

FACIAL NEURALGIA. 

Synonyms. — Face-ache; Fothergill's face-ache ; Prosopalgia ; Tri- 
geminal neuralgia ; Tic douloureux ; Migraine ; Sick headache. 

The supra-orbital branch may be alone affected, and the pain confined 
to the brow and top of the head, or it may be quite generally diffused over 
the face and head, the three branches being involved. The first division 
of the nerves is, however, the most common seat of neuralgia ; but it is 
not unusual for an attack to begin above, and finally extend to all of the 
divisions of the nerve on one side. 

Migraine, or " sick headache," presents the following features : The at- 
tack may be preceded by some chilliness, pallor, and uneasiness, and is 

^ American Journ. of Med. Sci. Iviii. 16. 
33 



514 DISEASES OF THE PERIPHERAL NERVES. 

ushered in by a twinge of pain, which begins just above the eye on one 
side, and radiates over the head. The pain is often erroneously referred 
by the patient to both sides of the head, when, in reality, but one-half is 
affected. Deep-seated orbital pain, photophobia, hemiopia and nausea, 
with an irritable, thready pulse, and increase of pain, immediately usher 
in the attack, which rapidly increases in severity ; the pulse after a while 
losing its asthenic character, and becoming full and bounding. The pa- 
tient's face becomes flushed, and his skin red and sweaty, and in rare 
cases the sweating is confined to one side of the face. The paroxysms of 
pain, which at first were separated by intervals of relief, next become al- 
most continuous, but after a time, during which the patient may feel like 
vomiting, they become less severe, and finally, after his stomach has been 
emptied, may disappear altogether. The features of an attack of this kind 
are too familiar to need elaboration. The following case will serve as an 
illustration : — 

Mrs. Gr. is a delicate, hysterical woman, who devotes most of her time 
to duties of society. Her domestic affairs are worrying, and the constant 
excitement of entertaining, late hours, and the management of several 
unruly children, have so worn upon her that now, at the end of the winter, 
she is ansemic, " run down," and suffers from want of appetite, insomnia, 
and general debility. About twice a week, at irregular times, she suffers 
in the beginning from light pains, radiating from the right eye, and over 
the head, which become quite severe, and increase during the next hour 
or two. She usually becomes cold, and bundles herself up in shawls and 
wraps. Her eyelids feel heavy, and the " skin covering " her " face feels 
as if it were drawn tightly." She is nervous and irritable, and cannot 
bear the presence of her children, and is sometimes so depressed that she 
bursts into tears. She has a vague dread of some trouble, the character 
of which she does not know. The pain increases in severity, and becomes 
almost unbearable. Her eyes are hot, and " it seems as if a peg was be- 
ing driven in from behind." Her face becomes very hot, and her tem- 
poral vessels throb. The slightest step she may take in wailking so jars 
her head that it gives rise to intense pain. She " feels as if" her " head 
would split open." She cannot look out of the window, but lies upon her 
bed, and buries her face in the pillows. Nothing seems to relieve her. 
She may lie so for hours, panting for breath, and pressing her aching head. 
After a variable time, sometimes two hours, sometimes a day, the pain is 
diminished somewhat, and she becomes nauseated ; not because food lies 
undigested, for she has taken none for some time, but the vomiting is of 
a purely cerebral character. She attempts to vomit, but cannot bring up 
anything. The effort at retching jars her body, and increases the pain. 
After this state of affairs has lasted for some little time, she becomes ex- 
hausted, and falls back upon the bed, sweating profusely. The pain grows 
very much less severe, is dull and throbbing, and finally she sinks into a 
deep sleep, from which she awakens somewhat relieved. 

The variations in pain and circumstances which give rise to the disease 
have led different observers to apply such names as " rheumatic," " hys- 
terical," "sympathetic," " organic," "syphilitic," and " clavus." These 
terms have little value, and it seems that a nomenclature based upon the 



NEURALGIA. 515 

anatomical situation of the neuralgia is all that is needed, and it certainly 
would do away with much confusion. Facial neuralgia, unless it be due 
to temporary exciting causes which may be readily removed, is rather an 
obstinate affection. It may take a periodic character, especially if it be 
connected with malaria ; or it may be more intense at night, should it be 
of syphilitic origin. The true attack rarely lasts beyond a few hours, but 
attacks (especially of tic-douloureux) may be so frequent as to become 
almost continuous. The tendency is, I think, for the disease to become 
firmly rooted, and to increase in severity. If there be a rheumatic, mala- 
rial, or anaemic form, there is no reason why the disease should not subside 
when these morbid conditions are removed. As to clavus, in which the 
pain is compared to that which would probably follow the driving of nails 
through the skull, it may be said that this is an hysterical condition, and 
the patients' descriptions are based upon the workings of a disordered 
imagination. 

There are very few cases of facial neuralgia in which all the branches 
may not be involved at some time or other. If the neuralgia be confined 
more particularly to the first and second branches of the fifth, the temples 
and forehead, upper eyelid, root of the nose, and the orbits will be the 
points at which the pain will be the most severe. Toothache, above and 
below, will indicate involvement of the middle and lower branches, and if 
the lingualis be afiected, which it quite rarely is, the tongue will be the 
seat of the violent pain. The painful points are ta be found principally 
over the supra-orbital notch, the infra-orbital foramen, the " malar point,'' 
or in the roof of the mouth, over the mental foramen, and in front of the 
ear. During the attack it is not uncommon to find hypersecretion of sa- 
liva, that fluid passing from the angle of the mouth in great quantity, and 
when the supra-orbital and infra-orbital branches are involved there may 
be a corresponding profuse lachrymation.^ Erb^ has called attention to 
the occasional increase of secretion from the nasal mucous membrane. 
This has been referred by Vulpian to irritation of one of the spheno- 
palatine ganglia. The patient is nearly always excited and irritable, and 
if the paroxysms be of frequent occurrence he suffers from insomnia, and 
is entirely unfitted for his daily occupations. It must not be supposed 
that the vomiting of migraine has any direct connection with the condi- 
tion of digestion. The attacks are, however, aggravated by the presence 
of undigested food in the stomach. 

The deep neuralgias of this nerve are very obstinate, and often beyond 
the reach of any treatment. This is notably the case when the superior 
maxillary or its orbital branches are afiected. The ocular symptoms are 
then of the most formidable description, and life to the patient is a burden 
indeed. 

The following is one of the most inveterate cases of neuralgia of this 
kind I have ever observed. The patient's trouble began in 1863, while 

1 Sometimes there is spasmodic closure of the orifice of the lachrymal duct. 

2 Ziemssen's Cyclopaedia, vol. ii. 



516 DISEASES OF THE PERIPHERAL NERVES. 

at school, and then affected the superior maxillary and infra-orbital 
branches of the fifth nerve. His sufferings were intense, and after 
trying almost all forms of treatment, and consulting medical men in 
Europe and in this country, he consented to subject himself to an opera- 
tion for exsection. The history he brings, which was taken by the house 
surgeon. Dr. Peale, of Chicago, details the surgical procedures under- 
taken. 

" Patient has for a long time suffered from neuralgia of supra- and 
infra-orbital nerves, and the superior trochlear nerve. Prior to this 
he had a closure of the lachrymal ducts of both sides. He had been in 
Central America, where he was exposed to severe forms of malaria. 
About two years ago, Dr. Strawbridge, of Philadelphia, cut off the supra- 
orbital nerves at their point of exit from the supra-orbital foramen. In 
either eye there is loss of accommodation, and a high degree of hyper- 
metropia. Prof. Holmes, of this city, after an ophthalmoscopic examina- 
tion, told him that the veins of the retina were diminished in size. 

He still suffers intensely with the infra-orbital nerves, and comes in de- 
siring to have them excised. He receives 3i grs. morphia, hypodermi- 
cally, each day. 

Dec. 18, 1876. An incision made downward from the location of each 
infra-orbital foramen to the length of one inch through the tissues of the 
cheek, the nerves raised on a blunt hook, stretched well out, and chipped 
off at their point of exit. Ether used as the anaesthetic, collodion and 
silk sutures to approximate the edges of the incision. 

l^th. Patient suffering from intense pain referred to outer edge of right 
lower eyelid, 

2M, Considerable cellular inflammation of right side of neck and 
face. 

2%ih. Considerable discharge of pus from incision on right side of 
face ; swelling very much diminished. 

'A^th. Discharge of pus from both incisions has now about ceased ; con- 
siderable cellular inflammation of right side of face in parotid region. 
He claims he has still the neuralgic pain, but deeper in the infra-orbital 
region. 

Zlst. Considerable swelling and a great deal of tenderness on either 
side of the neck below the jaw. Patient cannot move the jaw. 

Jan. 5, 1877. Face continues swollen, and very painful ; thinks he 
still has the old neuralgic pain on right side. Quantity of opiates in 
twenty-four hours considerably diminished. 

2%th. Patient again placed under the influence of ether. An incision 
made on the right side in the site of the old one, and the nerve raised on 
a blunt hook and divided. Following the operation the pain became 
severe, and the hemorrhage excessive. For a couple of hours all sorts of 
efforts were made to stop it, and finally we were obliged to resort to ol. 
terebinth, and ferri persulph. These, with compresses bound on as best 
we could, checked it so that it only oozed. A large quantity of anodyne 
was required to allay pain. 

30iA. There has been no further hemorrhage. Morph. pro re nata. 

Feb. 2. All dressing removed without hemorrhage; wound left open 
and suppurating ; dressed with carbolic acid ; pain controlled with 
morph. 



NEURALGIA. 517 

ith. Complains of pain in right temple. P. M. Severe headache ; 
wound dressed twice a day. 

llf/i. Patient had been doing well until yesterday. There was a hem- 
orrhage from the wound in the morning, controlled by syringing with 
cold water. Last night another very severe hemorrhage ; used dry ferri 
persulph. Has had three hypodermic injections of Igr. morph. each, 
daily. Ordered iodoform to be sprinkled in wound. 

March 27. At 3 P. M. patient was etherized, and Prof. Bogue pro- 
ceeded to resect the orbital branch of the superior maxillary nei'v^. A 
circular flap begun in the old cicatrix on the right side, and curving 
backwards, laid bare the malar bone. An opening was then made through 
its quadrilateral surface with a trephine into the antrum ; the floor of the 
orbit was then gouged away and the nerve hooked up and ruptured. 
There was, following this, hemorrhage. A plug of sponge was then 
stufled into the antrum and left. In the evening there was a severe 
hemorrhage from the nostrils and mouth ; the nostrils were plugged. 
Later in the evening the sponge and plug were removed ; the antrum 
washed out ; there was a brisk hemorrhage. Monsel's styptic was freely 
injected ; finally the antrum was again plugged with sponge soaked in the 
same solution. The eyeball was noticed to project considerably more 
than its fellow, but the sight was not much impaired. Patient has had, 
till the present time (10 A. M.), morph. gr. iij, by hypodermic injection. 
This morning complains of great pain in the eye and upper jaw. Plugs 
not removed. Ordered whiskey and morph. to allay pain. P. M. Pulse, 
76; temp. 103°. 

'mh, A.M. Pulse, 72; temp. 100°. 

Yesterday evening the sponge plugs removed from the wound ; no 
hemorrhage occurred ; they were not replaced ; water-dressing continued 
through the night. This morning the wound is suppurating slightly ; 
face not swollen quite so badly. Patient has had one grain morph. by 
hypodermic injection every 4 hours for the past 48 hours. Water-dress- 
ing continued. Patient still complains of great pain in the right eye ; 
swelling is considerable; eye closed, with conjunctiva protruding from 
between the lids. A pledget of lint saturated with alcohol was laid in 
wound, and water-dressing continued. 

April 1. Is feeling better ; wound is suppurating considerably ; is not 
swollen so badly ; plugged with lint saturated with alcohol, and the cold 
compresses continued. 

M. The surface of the wound is covered with healthy granulations. 
The eye very much improved ; can open it ; can distinguish objects at 
some distance. 

Uh. The patient's condition rapidly improved. 

Qth. Cavity granulating finely ; appetite good ; everything appears fa- 
vorable at this time." 

The patient cam3 to New, York and consulted me October 17, 1877. 
In spite of all the surgical operations the pain is as severe as it ever was, 
the focus of intensity being evidently the orbital branch. The eye is 
without sight, but no retinal changes can be discovered, except paleness 
at the fundus. The conjunctiva is injected, and the eye is suff'used. I 
gave him two hypodermic injections of morphia, of one grain each, within 
an hour, but none of the physiological effects followed, and the pain re- 



518 DISEASES OF THE PERIPHERAL NERVES. 

mained unabated. Nothing remains to be done but deep section of tbe 
nerve. 

A formidable neuralgia is that connected with spasm -of the facial mus- 
cles, which has received the name of tic douloureux or tic epileptiform. The 
former term is that applied by Benedikt, and has been generally accepted 
by most writers to express the violent and sudden twinges of pain which 
are accompanied by very forcible spasms of the facial muscles. These 
spasms may be of varying degrees of severity. The eye may be tightly 
closed during the paroxysm, or the face violently drawn to one side. 
The attacks are generally supposed to be confined to those individuals 
in whom there is a neurotic predisposition ; and Erb, Eulenburg, and 
others consider tic douloureux to be a disease of central origin, which 
seems very probable for some reasons, but not so much so when we take 
into account the fact that in some cases the disease may appear and dis- 
appear, there being occasionally a long period of quiescence, and then a 
relapse. Anstie considers that the spasm is not directly connected with the 
pain, but is rather inclined to look upon it as a coincidence, or as a result 
of the epileptic tendency, the pain and epileptiform spasm being separate 
expressions. 

A very interesting case, to which I have already casually alluded, was 
sent me by my friend Dr. Sayre, of New York. 

Mr. K. had for ten or twelve years suffered from neuralgia of the fifth 
nerve of the right side. His habits had been very good, and there was 
no history of syphilis, nor any evidence that it had existed. About ten 
years ago, after exposure, he first noticed the commencement of his trou- 
ble, and at this time there was no facial spasm or very decided pain ; his 
attacks, however, which, during the first two or three years, occurred at 
intervals of two or three months, became much more frequent, and, within 
three years, have become almost continuous, so that there is rarely an in- 
terval of five or ten minutes between each paroxysm. Sleep is utterly im- 
possible, and he has been obliged to resort to an immense quantity of 
stimulants for the purpose of procuring rest. 

He tells me that very often he drinks a pint of whiskey before retiring. 
During his visit he had several attacks of tic, during which his face was 
drawn up and agitated by clonic spasm of the muscles of the right side ; 
these attacks lasted one or two minutes, during which his face became 
flushed, his eyes injected, and from the corner of his mouth trickled a 
quantity of saliva ; the gum was very tender, and painful points before 
alluded to were found to be very sensitive. Numerous painful points 
were also found upon the scalp, over the supra-orbital notch, and at dif- 
ferent points over the temporal bone. Before I saw him he had been 
under several varieties of treatment, but none afforded him the least 
relief. 

CERVICO-OCCIPITAL NEURALGIA. 

When the posterior branches of the upper cervical nerves are the seat 
of neuralgia, the patient will complain of pains beneath the occiput, be- 
hind the ear, and sometimes at the under part of the lower jaw. The 
pain at the base of the occiput is most severe; but when the neuralgia in- 



NEURALGIA. 519 

volves the anterior nerve branches, and pain appears behind the ear and 
over the lower part of the face, this affection may be mistaken for neural- 
gia of the fifth pair. The pain is often insupportable, and is of a parox- 
ysmal character. It is, on the other hand, of a localized form, and so 
constant in some cases that the medical man may be led to suspect in- 
flammatory conditions of other parts. During the active pain the pa- 
tient may be unable to turn his head or open his mouth, and any muscular 
movement is attended with distress. The skin may be either hypersesthe- 
tic or anaesthetic, but more often the former, and I have had patients who 
were unable to bear even the pressure of a collar or other neck gear. 
The skin feels to the patient as if it were tightly drawn over the tissues 
beneath, and it sometimes may be red and appear swollen. The hyperses- 
thesia, when it involves the scalp, is so distressing that the patient is 
unable to place his head upon the pillow, or wear a hat unless it is 
much too large for him ; and heat seems to increase the discomfort to a 
marked degree. The post-cervical muscles may be the seat of cramps, 
during which the patient's head is drawn backwards or laterally down- 
wards. Painful points may be found in two or three situations, but most 
frequently where the great occipital nerve emerges. The spinous pro- 
cesses of the upper cervical vertebrae are often the seats of painful spots, 
and it is not rare to find that distress is caused by pressure at different 
places over the occipital bone. 

CERVICO-BRACHIAL NEURALGIA. 

A form of attack manifesting itself in severe pains, which shoot down 
the arms, hands, and back of the neck. Exquisite cutaneous hyperses- 
thesia is by no means a rare accompaniment, the skin being so tender to 
pressure that the slightest touch of the clothing will produce intense, suf- 
fering. The distribution of pain corresponds to the parts suppjied by the 
lower cervical nerves or regions which are innervated by sensory branches 
of the brachial plexus. 

Erb^ has given a diagram which demonstrates the districts of pain, and 
their source of supply, which may be made use of in tracing the course 
of the affected nerves. (See page 534.) 

My attention has been directed by Dr. Burral to a condition of neu- 
ralgia which is often mistaken for the so-called muscular rheumatism, and 
is probably due to an involvement of the circumflex as well as the pos- 
terior thoracic. The pain is not nearly so acute as that of some of the 
other neuralgias ; for example, the facial variety. It is dull and terebrat- 
ing, and resembles the agonizing though temporary pain which follows a 
blow upon the popularly called " funny-bone," or ulnar nerve, in its ex- 
posed position at the internal condyle. The pain travels down into the 
hand, and may be attended by a spasm of the muscles. There are points 
of tenderness which are extremely numerous. Pressure made over the 
supraclavicular space, just below the lower angle of the scapula, at the 

1 Ziemssen's Cyclopeedia, vol. xi. p. 146. 



520 DISEASES OF THE PERIPHERAL NERVES. 

exposed portion of the ulnar nerve at the elbow, and at the points of 
emergence of the superficial nerves of the arm and forearm as they pierce 
through the fascia, gives rise to pain. Occasionally there are tender 
spots over the cervical vertebrae. The skin of the arm is often cold, and 
areas of capillary emptiness are to be observed either during an accession 
of pain or between the attacks. In rare instances it is not unusual for 
trophic alterations to be manifested. In a patient under observation the 
right hand is reduced in size, the skin is dry, puckered and livid ; the 
lines of flexure of the fingers and hand are red, and much deeper than 
upon the other side of the body ; and the nails are crenated and irregu- 
lar. Erb alludes to an excessive sweating of the fingers. This form of 
neuralgia is decidedly inveterate, and when well established is attended 
by nocturnal exacerbations. The use of the affected hand is sure to ag- 
gravate or precipate an attack, and changes of temperature act usually 
in the same manner. 

A gentleman sent to me by Dr. Ives, of New York, had suffered in- 
tensely for a number of years, and his pain had become almost constant. 
When he neglected to cover his arm with cotton batting, but permitted 
his coat sleeve to come in contact with the skin, he would be in utter 
misery, so that he was obliged to cover it with some soft substance. He 
was very cautious in selecting a position at night, as the arm, if unsup- 
ported, dragged the muscles of the shoulder sufficiently to produce a 
paroxysm. 

INTERCOSTAL NEURALGIA, OR PLEURODYNIA. 

This is often mistaken for pleuritis. It is characterized by a pain which 
encircles the body, and may be referred by the patient to the region 
bounded by the crest of the ilium below, and the thorax above ; but it 
more commonly aflfects the lower intercostal nerves. The pain is always 
one-sided, and is dull and continued, but may sometimes be sharp and 
paroxysmal, radiating from the spine anteriorly. The skin is hyperses- 
thetic, and this is particularly the case if the neuralgia be attended by 
herpetic patches. The painful points are chiefly over the inter -vertebral 
foramen, and where the nerve pierces the muscles anteriorly. The rectus 
muscles contain painful spots at the points where the lower intercostal 
nerves pierce the investing sheaths. The patient during the paroxysm 
inclines his body to the affected side, as it were to relax the muscular 
strain ; he perspires freely, and his face wears a scared and anxious ex- 
pression, suggestive of great suffering. His breathing is " catching " and 
shallow, and attended by the least possible movement of the thoracic 
walls or diaphragm. 

SCIATICA. 

Sciatica is perhaps, next to facial neuralgia, one of the most trouble- 
some and familiar neuralgias. It rarely begins suddenly, but has a 
gradual onset, attended by a variety of disagreeable and annoying symp- 
toms. Cutaneous hypersesthesia, slight fatigue after walking, and " sore- 



NEURALGIA. 521 

ness," a sensation of dragging or of heaviness of the leg and foot, and a 
number of minor symptoms of a vague character precede the actual pain. 
This is exceedingly severe, and may exist in a dull form, and during its 
continuance there may be paroxysms consisting of twinges or " darts " 
shooting down the back of the leg. Should the patient, while sitting, 
place his thigh so that the nerve shall be pressed against the edge of the 
chair, the paroxysm may be precipitated. Anstie has divided sciatica 
into three varieties, one of which occurs during comparatively early life, 
and is connected with hysteria. It is dependent generally upon over- 
fatigue, and affects anaemic people. It is the form which attends irregu- 
lar menstruation, and the pain is quite severe. In this variety I have 
rarely found any painful points. 

Before the fourteenth year neuralgia of the sciatic variety is very un- 
common. In 124 cases collected by Valleix, none were under seventeen 
years of age. 

Sciatica of the second variety is a disease of adult life, and is a result 
either of exposure, or some such cause as continued pressure of the nerve 
through sitting in an uncomfortable position. It is not rare among busi- 
ness men, or clerks who sit upon high wooden chairs or stools, and' who 
generally do not support their legs by placing the feet upon the floor or 
the rounds of the chair. Anstie connected this "middle-aged sciatica" 
with premature decline, and states that the patients have rigid arteries, 
gray hair, and the arcus senilis; but I do not consider that these indications 
of decay have any very decided bearing upon the sciatica, especially in the 
form last mentioned. It strikes me rather that the causes w^hich produce 
the disease, with the exception of dissipation and perhaps syphilis, gout, 
or like affections, would be local. Some of the most intractable cases 
of sciatica I have ever seen were persons who were apparently in good 
general health. The presence of " painful points " is highly characteristic 
of this form. Foci of tender nerves may be found corresponding with 
the emergence of the sciatic nerves from the pelvis ; and also at various 
points corresponding to the cutaneous distribution of the posterior branches, 
as well as just below the crest of the ilium. Points of tenderness may be 
also found at various situations in the course of the nerve at the back of 
the thigh ; sometimes in the popliteal space, or at the head of the fibula, 
and in the depression below the external and internal malleoli. Atrophy 
. of the muscles of the thigh is not a rare consequence of the neuralgia in 
old cases, and is sometimes preceded by paresis. Tactile sensibility is 
diminished, and areas of anaesthesia or blanching of the skin are occa- 
sional results of a continued siege. The paresis of sciatica is of gradual 
appearance, and the patient may at first slightly drag his leg or limb. In 
some of the old cases the least movement of the limb is attended by pain, 
which is referred by the patient to the point where the sciatic nerve leaves 
the pelvis. Such atrophy may follow inactivity. 

A curious feature of the disease in some cases is the appearance of pain 
in different parts of the limb. In the case of a gentleman who came 
to me for advice, I found that there were two districts of pain : one 



522 DISEASES OF THE PERIPHERAL NERVES. 

of whicli included the upper part of the sciatic, the pain never passing 
below the middle third of the right thigh ; the other situated at the outer 
side of the leg of the same side. 

CRURAL NEURALGIA. 

When the pain is confined to the anterior and lateral parts of the thigh, 
it is properly included in the cases called by this name, but the region 
supplied by the crural and its branches, viz., the inner surface of the thigh 
and its anterior aspect, as well as the inner part of the leg and foot, is 
more often the seat of pain in the lower extremity than any other part 
except that innervated by the great sciatic. This pain is paroxysmal, 
very severe, and, like that of the cervico-brachial variety, most intense at 
night. The inner part of the leg and foot are most commonly implicated, 
and there is a subacute variety of pain which exists between the parox- 
ysms. Walking and muscular movements of any kind are painful, and 
the patient may find it necessary to use a crutch, or else is obliged to keep 
quiet. Foci of tenderness may be detected at the point where the crural 
nerve is most superficial, in the groin at the inner side of the knee, at the 
upper and inner edge of the patella, and at various points on the inner 
side of the foot and leg. Muscular atrophy, which is probably a result of 
insufiicient use of the limb, is sometimes a feature of the disease. When 
the pain is more severe at the knee-joint, we may find an enlargement of 
that articulation, and in some respects the condition may resemble ar- 
thritic inflammation ; but the cutaneous hypersesthesia is much greater than 
in the latter affection, while deep pressure does not produce the amount 
of pain it would in rheumatism. In many respects the pain may resemble 
that of posterior spinal sclerosis. 

THE VISCERAL NEURALGIAS. 

The visceral neuralgias, especially those found to be connected with the 
uterus and its appendages, come more properly within the province of the 
gynsecologist than the neurologist ; so a complete description would neces- 
sitate a consideration of the various pathological uterine states which 
would be out of place in this book ; therefore our description must be ex- 
ceedingly brief. The importance of these latter forms of neuralgia can- 
not be over-estimated. They are commonly of reflex origin, and depend 
very often upon some morbid condition of the uterus and ovaries them- 
selves. As Anstie remarks : " The amount and force of the peripheral 
influences which are brought to bear upon the central nervous system by 
the functions of the uterus and ovaries are greater than any that emanate 
from the diseases and functional disturbances of any other organ in the 
body." The menstrual period is that with which neuralgia of this kind 
is, in nine-tenths of these cases, associated. It is essentially connected 
with irritability of the pelvic organs of the female, either when there is 
amenorrhoea and dysmenorrhoea, or when the generative apparatus is over- 
excited by immoderate copulation or masturbation, or during the preg- 
nant state. When there is any mechanical condition of narrowing or 
occlusion of the cervical canal, prolapsus uteri, intra-uterine growths. 



NEURALGIA. 



523 



ulcers or reflected irritation,neuralgiaisnot at all a rare accompaniment. 
I have found it very often as a symptom of general ansemia, with no ap- 
preciable uterine disease whatever. 

■ OVARIAN NEURALGIA. 

Ovarian neuralgia is symptomatized by excruciating pains radiating 
from these organs. It is not necessary that there should be derangement 
of menstruation, though such is generally the case. The pain may some- 
times be dull, but is more apt to be quite sharp. It is greatly increased 
by standing, or by fatigue following protracted use of the lower extremi- 
ties. Among sewing-machine operators it is especially common, and many 
of my cases have been of this kind. It is generally connected with con- 
stipation or a sluggish condition of the circulation, sometimes leucorrhcea, 
hysteria, and always with a great deal of weariness and prostration. The 
suffering may be so intense and protracted as utterly to wear out the 
patient, and unfit her for any labor. It may be bilateral or unilateral. 
There are various other forms of neuralgia which depend upon reflected 
or local causes. 

URETHRAL NEURALGIA. 

This is not infrequently associated with stricture, gonorrhoea, or mas- 
turbation. It may be quite obstinate and of a paroxysmal character, and 
is much worse at night. I have found it very often where there has been 
a contracted meatus, in which case the pain ran up the penis. Vesical 
neuralgia, which may be connected with the presence of a stone, or which 
occurs as a result of long-standing cystitis, is symptomatized by pain at 
the neck of the bladder, where there may be some tenesmus. 

RENAL NEURALGIA, ETC. . 

Renal neuralgia cannot be diagnosed with certainty, and probably the 
pain is in many cases due to the presence of calculi. Neuralgia of the 
testis is symptomatized by sharp pains of a temporary character ; and it is 
generally due to some distant source of irritation, such as the descent of 
a renal calculus, or the presence of a vesical calculus. I have seen cases 
which have followed excessive venery ; and Anstie reports a case of epi- 
lepsy in which this form of neuralgia was undoubtedly the exciting cause. 
Self-abuse produced the "testicular neuralgia," which in turn precipitated 
the fits. With the pain there were vomiting and great prostration. Asca- 
rides in the rectum may give rise to neuralgia of that gut. The pain is 
nearly always about the anus or just above the sphincter, and darts 
upwards. Cold or exposure are given as causes. The breasts are often 
the seat of a very painful neuralgia, which has been called mastodynia. 
This is, in reality, a form of intercostal neuralgia, in which case the 
anterior and middle cutaneous branches of the intercostal of one or both 
sides are affected. It appears at puberty, or may accompany lactation 
when the nipples are cracked. In both these classes of cases there must 
be a lowered nervous condition ; and, according to Anstie, masturbation 



524 DISEASES OF THE PERIPHERAL NERVES. 

precedes the trouble in the youthful patient, while it is extremely proba- 
ble that the strain upon the nervous system during pregnancy and lactation 
is often much greater than the badly-nourished patient can bear. I have 
met with the affection in perfectly healthy patients, and am convinced that 
the pain was purely neuralgic, and not dependent upon any inflammatory 
condition of the nipples. One of these patients was a prostitute, and had 
assiduously followed her trade, meanwhile losing sleep, and drinking to 
excess. 

Causes. — For the sake of conciseness, I may group the causes which 
are predisposing and exciting under the following several heads : — 

1. Hereditary. 

2. General diathetic (anemia, rheumatism, alcoholism, gout, syph- 

ilis). 

3. Psychical (intellectual, emotional). 

4. External (cold, pressure). 

5. Sexual. 

6. E-eflex. 

Hereditary Predisposition plays a most important part in the genesis of 
neuralgia, so important indeed that it is difficult to find cases of this dis- 
ease in whom there has not been some family history of previous nervous 
trouble. Insanity, paralysis, alcoholism, or convulsive disorders may be 
traced back ; and of twenty-two cases collected by Anstie there were but 
five in which there had been no family neurotic history, and in some of 
these phthisis was found. This disease, according to Anstie and others, 
seems to play quite an important part in the causation of neuralgia ; 
and in one minutely detailed history given by him the appearance of 
tubercular meningitis and other neuro-phthisical diseases followed the 
engrafting of the pulmonary trouble upon the neurotic stock. Epilepsy 
enters extensively into the causation of many forms of neuralgia, especially 
epileptiform tic ; and not only may these other neuroses have appeared 
among the progenitors of the individual, but they actually exist with the 
neuralgia. 

Blandford ^ has called attention to a form of insanity which coexists 
with neuralgia, the pains subsiding during acute mental disturbance, and 
reappearing with its subsidence. Migraine is too common an accompa- 
niment of epilepsy to need more than a passing allusion. Chronic alco- 
holism is associated with a variety of neuralgic headaches and pains in 
the lower extremities, which are quite intense. Certain general diseases, 
which produce a cachectic condition, quite often give rise to the disease, 
not only by actual mechanical disturbance of the nerve-functions by effu- 
sion and periosteal disease, but through the condition of mal-nutrition and 
enfeeblement of the nervous system which originates in malaria, gout, 
rheumatism, and syphilis. The influence of malaria in the production 
of neuralgia is markedly seen in the South and South-west, where the 

1 Insanity and its Treatment, p. 95. 



XEUEALGIA. 525 

most violent attacks of neuralgia yield only to large closes of quinine and 
arsenic. The neuralgia is generally of the facial variety, but it may take 
the sciatic or any of the other forms. In many cases it is periodic, or 
occurs in connection with the chill and other features of the malarial at- 
tack. In most of the cases I have seen, it followed generally after a pro- 
tracted siege of "fever and ague," when there was extreme debility, 
" bone-ache," and enlarged spleen. 

Lumbo-abdominal neuralgia is far from being an uncommon malarial 
state, and is sometimes very apt to be mistaken for renal colic. Gout and 
rheumatism are not looked upon by Anstie as diseases which play a very 
important part in the general causation of neuralgia, from which opinion 
I am inclined to dissent. Putting entirely out of question the local inflam- 
mation of the nerve sheath, which is so often a cause of sciatica and other 
neuralgias, I am convinced that there are forms of the disease, aggravated 
by changes in temperature, coexisting with painful joints and extremely 
acid urine which disappear under alkaline treatment, and are not clearly 
examples of nerve-sheath inflammation. Gout, inducing veiy often a 
condition of general or cerebral anaemia, has been in my experience, a 
very frequent cause of facial and other neuralgias. The condition of the 
liver, which occasions cerebral anaemia, melancholia, and over-loaded 
bowels, may also induce a neuralgia of a functional character. Not only 
in the tertiary form of syphilis, but, long before this, neuralgia may often 
be a troublesome symptom. I have had recently under my care an indi- 
vidual who had two years ago a primary sore, and has since had secondary 
symptoms. A chancroid, recently contracted, assumed a phagedenic char- 
acter, and there were great debility and severe neuralgia, which succumbed 
under specific treatment and nourishing diet. Profound anaemia is very 
often found to be the origin of neuralgia of various kinds. In women 
who have lost much blood during the menstrual flow, or in others who 
have become exsanguined from hemorrhoids, neuralgia is not to be looked 
upon as an unusual complication. 

The various constitutional diseases just alluded to may produce various 
forms of neuralgia, by inflammation of nerve-sheaths, with deposit, or, as 
in the case of syphilis, gummatous growths ; or periostitis may make dan- 
gerous pressure upon the nerve-trunk at some point where the latter is 
unable to withstand it without injury to itself. Syphilis, in rare instances, 
produces irritation in the nerve-trunks themselves, giving rise to pain. 
This irritation, however, much more frequently produces motor paralysis 
than sensory disturbance. Mental overwork, shock, and a continued ab- 
normal play of the emotions are likely to give rise to neuralgia, and for 
this reason literary men and hysterical women suffer very frequently. 
The headache of the overworked school child, compelled to overtax its 
brain, and dependent upon confinement in a hot room, is far too common. 
Want of amusement, deep grief, and the pursuit of one narrow line of 
thought, are all influences which lower the integrity of the nervous system, 
and give rise to this as well as other neuroses. Anstie's practical and 
judicious reasoning in regard to false religious training, and the dangers 



526 DISEASES OF THE PEKIPHEPwAL NEKVES. 

it may bring in the way of forcing the individual to become self-conscious, 
should suggest to the physician and parent the necessity for avoiding 
everything in education which promotes brooding, causes the individual 
to torture himself with doubts and self-accusation, and narrows the mind, 
thus depriving the nervous system of its normal exercise. Constant worry 
about business and any strain which demands an unusual expenditure of 
brain-force are causes of this kind. Exposure to cold and damp, par- 
ticularly if there be wind, is a fruitful exciting cause of neuralgia, and 
persons who are exposed to draughts in railroad cars and public buildings 
very often owe their attack to such agencies. Pressure from various 
growths, cystic, cancerous, and gummatous deposits, not rarely causes dis- 
tressing and intractable neuralgias ; but a syphilitic growth has been 
known to entirely surround a nerve-trunk without interfering materially 
with its functions.^ Neuromata very frequently give rise to neuralgia. 
8uch neuromata sometimes follow amputation or gross nerve-wounds, and 
the neuralgia is generally relieved by extirpation of the nerve-tumor. 
Various local troubles of a peripheral or remote nature, produce neural- 
gia, and among these may be mentioned carious teeth, ascarides, and renal 
calculi. When carious teeth give rise to neuralgia, it is always very ob- 
stinate, and the cause may remain unsuspected for a long time. 

Baiter has observed cases of cervico- brachial neuralgia from bad teeth ; 
the variety most frequently met with however is facial neuralgia. This 
cause is ordinarily supposed to account very frequently for the head neu- 
ralgias, and many sound teeth are sacrificed by the individual, while 
there may be neuralgia of the two lower branches of the hfth from other 
causes. Over-use of the eyes, and consequent fatigue of the muscles of 
accommodation, are supposed by some to have much to do with its pro- 
duction. KenaJ or urethral calculi, gonorrhoea, masturbation, and ex- 
cessive venery, are all reHex causes of importance, and play a part in the 
production of lumbo-abdominal and other neuralgias. Uterine disease 
and overloaded bowels, or, a fibrous tumor in the rectum, may by pressure 
often produce sciatica of • a very obstinate variety, and aneurism more 
rarely makes pressure which gives rise to neuralgia. Digestive derange- 
ment and prolonged lactation may be mentioned as additional conditions 
which favor the production of neuralgia. As to age and sex, it is the 
opinion of most authors that neuralgia usually originates at the age of 
puberty, but the disease is most common between the twentieth and fiftieth 
years. The following table, presented by Erb (Ziemssen, vol. xi.), pos- 
sesses statistical value : — 

Valleix. Eulenburg. Erb. Total. 



Period of life up to 10 years, 


2 


6 


— 


8 


'^ 10 to 20 '• 


22 


19 


14 


55 


« << 20 t'o 30 *' 


08 





40 


108 


- 30 to 40 " 


67 


33 


39 


139 


«' 40 to SO " 


64 


23 


29 


IW 


« '* 50to«0 " 


47 


14 


14 


75 


'* 60 to 70 '' 


21 


6 


9 - 


36 


" 70 to 80 " 


5 


— 


1 


6 














296 


101 


147 


543 



Huebner Ziemssen's Cyclopaedia, vol. xii. 



NEURALGIA. 527 

As to sex, Yalleix collected 469 cases, 218 of whom were men ; Euleu- 
burg 106, of whom 30 were men; Anstie 100, of whom 33 were men; 
Erb 146, 84 being men. Of course there are varieties of neuralgia which 
are confined more to certain ages and sexes. Migraine is more general 
among women, while sciatica is probably more often a disease of males. 
Anstie considers facial neuralgia to be a disease of adult life. So 
far as climatic influences are concerned, neuralgia is predisposed, and 
very often markedly affected by sudden changes in temperature. Dr. 
Weir MitchelP has written a very valuable paper upon the subject, 
which clearly shows the very decided influence of modifications of 
temperature and humidity. His article is based upon the personal 
notes of Captain Catlin of the IJ. S. Army, who sufiered from 
stump neuralgia, and who intelligently and carefully noted the influences 
of atmospheric changes. Captain Catlin's conclusions were as follows : 
" Neuralgic intensity does not seem to be proportioned to the amount of 
rain-fall. At the exterior of a storm disturbance the pain is usually 
severe, and, indeed, at times I have been so far from the disturbed centre 
as to just perceptibly feel it. A storm, reinforced by another at an 
angle of say 90°, producing greater eccentricities in the curves, does not 
seem to produce a corresponding intensity of duration of the neuralgia." 
He adds : " I am unable to state at what point within the disturbed area 
the pain would be strongest. The abruptness of the barometric fall does 
not seem to have much to do with the causing of pain, nor is the length 
of attack dependent as it seems on the length of the storm." 

Pathology. — Neuralgia is always the result of lowered functional ac- 
tivity dependent upon the trophic disturbance of a sensory nerve. This 
is probably attended by some change in the posterior nerve-roots, which 
is not necessarily inflammatory. The morbid anatomy of neuralgia has 
thrown but little light upon the pathology of the disease, so our conclu- 
sions must be based upon purely theoretical grounds. Erb, in speaking 
of the nutritive disturbances, says : " In regard to the ordinary seat of this 
trophic disturbance, nothing accurate is known ; but it is probable that 
the seat varies, and this much appears certain, that for the most part a 
definite group of fibres (or their central terminations) as they are com- 
bined to form a nerve-trunk or branch, is afifected. At what place in the 
length of the nerve this is present it is difiicult to say, and perhaps may 
be at any length. The peripheric fibrils may be affected at various points 
and various lengths of their course, or the posterior roots and their pro- 
longation in the spinal cord may be the seat of the neuralgic trophic 
disturbance ; or, lastly, the central fibrils running in the spinal cord or 
brain may be affected up to the terminal central apparatus. The inves- 
tigations that have hitherto been made have acquainted us with many 
important facts, but have furnished no very satisfactory conclusion." 

The clinical features of neuralgia enable us to understand many of the 
phenomena which ordinarily characterize the disease, and we are permitted 

1 American Journ. of Med. Science, April, 1877, p. 305. 



528 DISEASES OF THE PERIPHERAL NERVES. 

to assume that lowered nutrition from general or local disease, reflected 
irritations, and mechanical pressure enter into its production. Instead 
of a normal stimulus being conveyed by a healthy nerve to the centre, the 
nerve may be functionally impaired for conduction, or the centre so altered 
in its receptive faculty that the sensation period is grossly exaggerated. The 
receptive faculty of the peripheral fibrils may be so exaggerated that ordi- 
nary stimuli are received and transmitted in a painful form. Why the dis- 
ease should be paroxysmal we do not know. 

Of late much discussion has followed the presentation of a new instru- 
ment by Vigoroux for the treatment of neuralgia, and the nerve-current 
theory has been the subject of earnest inquiry and speculation. In this 
percuteur a small hammer is made to tap the surface of the body over the 
neuralgic nerve, and, while rapid tapping relieves dull pain, slow tapping 
is most efficacious in violent neuralgic pains. In the healthy subject any 
kind of tapping produces pain where none existed before. Granville and 
Vigoroux, both of whom claim to have invented the instrument simulta- 
neously, hold that neuralgia is the result of an irregular current wave 
or vibration. 

Morbid Anatomy. — It is by no means a matter of necessity that a 
nerve which has been the seat of neuralgia is found to be changed in 
structure. Accidental atrophy, hypersemia, and indications of neuritis 
are sometimes exhibited. Thickening of the nerve and sheath deposits 
in its neighborhood, or enlarged vessels, tumors, aneurisms, and the like, 
are occasionally met with. On the other hand, nerves have been removed 
which have been perfectly healthy. In old cases of neuralgia the posterior 
nerve-roots are nearly always atrophied. 

Diagnosis. — We may briefly sketch the character of the symptoms. 
The pain of neuralgia is paroxysmal or dull, with paroxysmal recurrences ; 
rarely tenderness upon pressure, except at certain situations. Neuralgic 
pain is rarely constant, while that of neuritis is quite so. The pain of 
neuralgia follows the course of some nerve, is quite acute, and has a lanci- 
nating, terebrating, or shooting character. It is also connected with vaso- 
motor changes in the skin. The existence of a cause must be considered, 
and the fact whether " hereditary predisposition " is present or not. Facial 
neuralgia is very rarely mistaken, and should not be when the fact is taken 
into consideration that the pain is generally referred to one of the branches 
of the fifth nerve. Pleurodynia is sometimes confounded with pleuritis, 
but the absence of physical signs should be sufficient to make the diagnosis 
clear. Lumbo-abdominal neuralgia is very frequently confused with vari- 
ous painful affections of the viscera. Among these may be mentioned renal 
colic, the pain of nephritis, and intestinal colic. Sciatica, from its unilateral 
character, is not likely to be mistaken for any other affection. The im- 
portant indication in diagnosis is to determine the variety of neuralgia, 
whether syphilitic or malarial, whether due to compression or connected 
with neuritis, or whether due to enlargement of, and pressure from, any of 
the abdominal organs. 



NEURALGIA. 529 

The following are to be remembered and consulted for guidance in mak- 
ing a diagnosis — 

A. Cause ; history of previous attacks. 

B. Character of pain ; paroxysmal, inconstant. 

C. Aggravation by debility or fatigue. 

D. The presence of " painful points." 

E. Its distribution (following course of nerves). 

F. Rarely aggravated by pressure, except at limited points, which 

correspond to superficial course of the nerve. 

G. Its general unilateral character. 

Prognosis. — Neuralgia of all kinds is more curable in early life than 
in advanced age, and it may be assumed that, when it has lasted for many 
years, and is severe in character, it will be most intractable ; this is espe- 
cially the case in the disorder known as tic epileptiform, which may be said 
to be nearly always incurable. In these troublesome cases even removal of 
the nerve affords but temporary relief. When atrophy of muscles has taken 
place the chance of cure is very remote, and if the cause be a deep one, such 
as pressure for instance, nothing can generally be done. There is a bright 
side of the picture however. Functional neuralgias, or those of the syph- 
ilitic variety, readily succumb to proper treatment ; and sometimes gene- 
ral nourishment and the removal of the exciting cause will speedily restore 
the patient to his normal condition. 

Those neuralgias which develop later in life are attended by structural 
decay, arterial degeneration, and are very hopeless. As to the curability 
of the varieties of neuralgia, that of the fifth nerve is most persistent, 
and intercostal neuralgia perhaps least so, whilst sciatica holds a place 
midway between the two. As an example of a severe and intractable 
continued neuralgia, connected probably with angina pectoris, I may 
present the case of 

Lucy L. S , sixty-five ; U. S. ; married. Previous History. — When a 
young child she fell, striking her right eye on a chair-post. For several 
days it was supposed she had lost her sight, but this was found not to be 
the case. After this she had pain in the left side and shortness of 
breath, whenever she attempted to run. At twenty-one she had an attack 
of cerebral hemorrhage, which affected the right side, but there was no 
aphasia. This was accompanied by anaesthesia, which has never entirely 
disappeared. About this time there were diplopia and ptosis — the latter 
symptom being now present. Supposed pulmonary trouble at twenty- 
four. Married at twenty-five. 

" Before birth of my second child, I was subject to dizziness, and neu- 
ralgia of the fifth nerve, which was most intense in the morning. 

When nearly twenty-eight, and my second child was a few days old, I 
' commenced to see dark spots, sometimes like black specks, again like 
circles with spotted centres.' When this child was three or four weeks 
old, sharp pain commenced in right side of the head. After sleep the 
pain would subside, and vision would improve. At intervals of from three 
to four weeks, or when tired, these blind attacks would return, accompanied 
either by sharp pain or dizziness in the head. For the next eight years 
34 



530 DISEASES OF THE PERIPHERAL NERVES. 

I was comparatively well, having occasional 'blind turns' when tired. 
At these times my forehead would feel as if strings were being pulled in 
opposite directions, and there was much twitching in the right eye. All 
these years there was some pain about the heart, with palpitation. 

At forty-one the change of life commenced, and I suffered several years 
most intensely. 

All these years 'there was some difficulty around the heart. Palpitation 
and some pain at intervals. 

For the past three years pain has been about equally divided between 
head and heart ; sometimes commencing in one and sometimes in the 
other. Some six months ago pain seemed to be settling around heart 
particularly. AVould come on with a chill and creeping sensation up the 
spine, and would begin with a whirling in left side. A palpitation of the 
heart would come on if excited or tired. Outward applications and 
medicine taken seemed to drive pain across from left side to right shoulder. 
Would go into right side of the head ; follow down right arm into hand. Also 
into left arm and hand. Hands have been much drawn up, and streaked 
with red. When pain was in face it would be spotted red and white on 
right side only. When severest in side and heart, eyes became set in 
head; face livid, and blood would settle under nails. Afcer enduring 
pain, tremble much in limbs." 

I saw the patient during the past spring, and found her to be a rather 
spare, badly-nourished woman, and she presented the following symp- 
toms : — 

Objective. — The right eye was examined and found to be sightless ; the 
retina was the seat of an old neuritis, with atrophy of the disk. There 
was slightly developed ptosis of this eye, and some keratitis, corneal 
opacity, and ulceration, and she was obliged to wear a shade The 
right side of the face was slightly ansesthetic and analge-ic. Jl)sthesio- 
meter contact and extremes of temperature were not readily perceived. 
The same was the case in the skin of the right arm, forearm, and hand, 
but more decidedly the latter The hand presented the appearances to 
be hereafter described (see article upon Neuritis), and was markedly 
anaesthetic, and the skin showed evidence of impaired nutrition. The 
right lower extremity was in much better condition. There was very 
slight loss of motor power on the right side. 

Subjective. — She now has attacks of severe facial and cervico-brachial 
neuralgia which come on every two or three weeks, and has had one within 
a day or two; there is still some tenderness' left in various parts of the 
face and right upper extremity. The pain seems most intense in the 
upper branches of the fifth, and has never affected the inferior maxillary 
to a decided degree. The arm pain and head-pain are simultaneous in 
their onset, and are preceded by the ordinary prodromata of an attack of 
this kind. They are always paroxysmal, and seem to reach a climax and 
then subside. During the attack the eye is seemingly " forced forward.s." 
After the attack she is entirely free from pain. With the seizure there 
is cardiac trouble, and respiratory trouble which suggests some impair- 
ment of the pneumogastric. 

She never has convuls^ions or vomiting, and there is no deep, localized 
pain at any point in the superior aspect of the cranium ; but all pain 



NEUEALGIA. 531 

at this point is superficial, and would evidently come under the head of 
hyperse.-thesia. 

In this case there is a decided hereditary history of nervous disease. 

Treatment. — In nine-tenths of the cases of neuralgia the manage- 
ment of the disease should be undertaken with the assumption that the 
pain is due to lowered functional activity and depressed tone ; and while 
local treatment is not to be forgotten, it is absolutely imperative that the 
patient should be supported, and that drugs which improve the nutrition 
of the nervous system should be selected. It is well to minutely inquire 
into the existence of other disease, and reference to what I have already 
said about etiology will furnish the reader with such hints as may be 
necessary. Should menstrual irregularities, gastric derangement, or con- 
stitutional diseases be found, it is well, I may say absolutely necessary, 
that these should be corrected before any local treatment is to be under- 
taken. 

Neuralgic pain is very variable ; and although, for my present purpose, 
I shall make use of two expressions to denote its character, there is much 
that must necessarily remain unsaid in regard to its variation and pecu- 
liarities. 

I shall describe the pain of neuralgia as coarse and fine, two divisions 
which, though somewhat arbitrary, are useful when we speak of treat- 
ment. Fine neuralgic pains may be said to be those of a sharp paroxys- 
mal character, leaving behind no points of tenderness, and entirely un- 
connected with any suspicion of neuritis. Coarse neuralgic pains may be 
said to include the brusque pains, which bring local tenderness and sore- 
ness, and are aggravated by movement. The former are those which 
sometimes occur during migraine and functional neuralgia of the lighter 
kinds ; while the coarse pains may be often the result of sciatica, in which 
the movement of the limb in walking or the pressure of the chair is suffi- 
cient to give rise to them. In one form of the latter our treatment should 
be quite negative, and of a character which necessitates the use of coun- 
ter-irritants, such as blisters and the actual cautery ; while the former is 
best treated by remedies which either increase the blood-supply of the 
nervous centres and improve their tone, or allay reflex irritability. The 
treatment of facial neuralgia or migraine should be the following : The 
use of diffusible stimulants ; muriate of ammonia being, perhaps, one of 
the best. It should be given in large doses quite frequently, beginning 
with from twenty grains to a drachm, which should be repeated every 
hour during the attack. Coffee and tea, or their alkaloids, are often ser- 
viceable ; or we may prescribe guarana, which is a very valuable remedy, 
in do^es of half a drachm to a drachm every hour. I have never wit- 
nessed any bad results from the use of this drug, even when quite large 
doses were taken. The powder is the best preparation. Tr. belladonna 
given in small repeated doses, does much good if the disease be of a re- 
flex character. The drugs recommended for this variety of neuralgia 
are quite as numerous as most of them are useless. The alkaloids 



532 



DISEASES OF THE PERIPHERAL NERVES, 



Fig. 6Q. 




Corrv.TIIiudzs 



Dap Peroneal, 



NEURALGIA. 533 

SuPERMCTAT, PoiNTS AND Cdtaneous Areas OF Nerve DISTRIBUTION. — 1, 2, 3,4. Poiiits for galvani- 
zation of tiftli nerve. 5. Brachial plexus. 6. Musculo-cutaneons. 7. Median. 8, 9. Ulnar. 11, 
12, Crnral. 13. Peroneal. 14. Tibial. 1.5. Occipital. IG. Radial. 17, 18. Sciatic. 19 Popliteal 
30. Peroneal, ac. Acromial. Cir. Circumflex. Int. h. Internal humeral. Ext. c. External cu- 
taneous. Int. c. Internal cutaneous, c. p. Cutaneous palmaris. p. u. Palmaris ulnaris. m. 
Median. Rad. Radial, u. Ulnar. Mu&. Sp. Musculo-spiral. Iho-Hy. Iliohypogastric. I. I. 
lUo-inguinal. Lat. Cut. Lateral cu'aneous. E. S. External spermatic. Lnm. I. Lumbo-ingui- 
nal. Pos. C. Posterior cutaneous, ob. Obturator. Com. p. Communicating peroneal In. sn. 
Internal saphena. ,Si<p. p. Superficial peroneal, cpm. Posterior median cutaneous. Cpp. Cuta- 
neous plantaris proprius. PU. Plantaris lateralis. 

daturine and conia have been used in obstinate cases of tic epileptiform 
with varying degrees of success, but great care should be taken. I have 
often broken up an attack of ordinary facial neuralgia with a cup of 
strong hot tea, or even a cup of hot water ; and now have a patient who 
has been in the habit of taking an emetic, which has almost immediately 
given her relief. Cannabis indica, either in the form of the extract or 
tincture, is of service when guarana fails. Its use should be continued 
for several months. If the neuralgia be malarial, a fair dose (say 
twenty grains) of quinine rarely fails to abate the paroxysm. As local 
applications, various stimulating liniments are used, the best I know 
being the compound soap-liniment; or a mixture of chloroform, tr. 
aconite and camphor; an ointment of veratria or of chloral and camphor 
sometimes affords relief, and I have witnessed the good effects of a tinc- 
ture made of the berries of the belladonna. The blister or actual 
cautery may be brought into requisition if painful points are found, and 
I have been in the habit of using the ether spray just in front of the 
ear in migraine. In tic douloureux I ana convinced there is no better 
remedy than gelseminum given in large doses, beginning with "Iviij to 
»n.xv of the tincture or fl. extract. My friends Drs. Kinnicutt and 
Clymer have both mentioned to me the details of cases where by accident 
the patient had taken toxic doses of this drug. In one of these the 
disease entirely disappeared after the alarming effects of the remedy had 
passed away. Croton-chloral, which has lately been recommended for 
facial neuralgia, I am convinced has been overpraised ; I have given it a 
fair trial, and have rarely found it of any use. If it is employed twice a 
day in twenty-grain doses, it will do more good than in the small repeated 
doses. The removal of carious teeth is often followed by speedy disap- 
pearance of the disease. Should the face become tender, as it not 
uncommonly does, the patient should be directed to keep it carefully 
protected by cotton-batting ; and if painful points remain in the roof of 
the mouth or gums, they may be lightly touched with the hot glass rod 
or iron. The treatment of cervico-brachial, cervico-occipital, and other 
neuralgias of the trunk may be managed after very much the same plan. 
In each particular case of course the treatment varies. If there be a 
diathetic condition, such as syphilis, mercurial inunctions, baths and 
specific treatment are to be made use of in conjunction with local appli- 
cations. The advantage of large doses of quinine in cachectic headaches, 
as well as in intercostal or lumbo-abdominal neuralgia, especially if there 
be an herpetic eruption, I have mentioned. In these forms, as well as in 



534 DISEASES OF THE PERIPHERAL NERVES. 

ovarian neuralgia, the use of local colrl, such as may be obtained by 
ice-bags, or the application of blisters, is very eiRcacious. The actual 
cautery, employed to make sweeping strokes along the course of the 
nerve, or down the back on either side of the spinous processes, and in 
paths which run at right angles to the longitudinal " stripes," may be 
brought into requisition, and applied twice or thrice weekly. Sciatica 
sometimes demands most obstinate treatment. The actual cautery, and 
even nerve-stretching, may be necessary ; but in the majority of cases 
galvanization of the nerve does great good, and should be faithfully tried 
before anything else is done. In neuralgia of the rectum it will often be 
found that stretching of the sphincter ani will effect a rapid cure, espe- 
cially when fissure exists. 

Electricity affords very decided relief in this disease ; and galvanism, 
when judiciously employed, rarely fails to modify, if not cure neuralgia. 
In facial neuralgia it should be applied to the nerve by small sponge- 
covered electrodes, one pole being placed just behind the condyle of the 
jaw, and the other held for a few minutes over the supra-orbital and 
infra-orbital foramina, or over the symphysis of the lower jaw. The 
current should be the direct (from positive to negative, the negative pole 
peripheral). The plates of Morgan, and the suggestions of Zierassen, 
will enable the reader to comprehend the situation of the points corres- 
ponding to the superficial course of the various nerve-trunks, so that they 
shall be brought most readily under the influence of the current. Fara- 
dism of the intercostal nerves, and of regions of distribution of terminal 
filaments of other nerves in various neuralgias, is of great service, and 
rarely fails to afford relief in sciatica. I have seen pleurodynia disap- 
pear in ten minutes after the use of the faradic current. The following 
case shows the benefit of electrical treatment. 



Mr. S. After constant exposure during the war, the patient con- 
tracted a low typhoid fever which left him weak and emaciated for a 
long time. Since 1868 he has had twinges of pain down the back part of 
the leg, which have left him in a perpetual state of misery, with only 
occasional intervals of several months when he is absolutely free from 
pain. In winter his trouble is worse, and any exposure will immediately 
produce a severe attack of neuralgic pain. Any indiscretion in his diet 
will also be followed by the sciatica. He had gone through the usual 
sieiie of medication, including morphine, hypodermics, and stimulating 
lotions. He came to me in July, 1871, when I made applications of 
galvanism to the nerve by the conical sponge-electrode, the sponge being 
held firmly over the obturator foramen. At the first visit his pain was 
excessive, but after fifteen minutes' application he left, feeling a sense of 
relief which he had not known for months. Two months and a half of 
this treatment were sufficient to dispel the pain, which did not recur. 
Four months afterwards, he mdde a visit, when he stited that he had not 
had any return. 

Less than one year ago Granville described an instrument for the 



NEURALGIA. 



535 



treatment of neuralgia, which effects the mechanical transmission of 
shocks to a nerve which may be the seat of neuralgic pain. I have not 
seen Granville's instrument, which consists of a hammer driven by a 
rachet wheel, and so regulated that rapid or slow shocks may be made. 
I have, however, carefully followed out his experiments with an instru- 
ment which consits of a tuning-fork, (c) vibrated by electricity, and solidly 

Fig. 67, 




mounted upon a hoard. The board is provided with an arm, (b) which 
can be applied to the superficial part of the nerve. By means of set screws 
{a. a.) coarse or rapid vibrations may be produced, (d) is an electro- 
magnet. In acute pain the slow vibrations are communicated to the 
nerve trunk, destroying the irregular character of the painful impression, 
and often affording instant relief. The curious reflex phenomena that 
result sometimes are indicative of a very profound nervous impres.-ion. 
In my personal experiments I was able to provoke a synchronous vibra- 
tion in the tensor tympani muscle with subjective throbbing and noises; 
and an ocular impression manifested in momentary flashes such as are 
produced by the galvanic cuirent. 



536 DISEASES OF THE PEEIPHEEAL NERVES. 

In the treatment of neuralgic attacks the hypodermic syringe has 
played a very important part. I have no doubt that it has been abused, 
and I have become painfully aware that individuals have thus acquired 
the habit of opium and morphine self-administration. For the radical 
cure of certain varieties of neuralgia, the hypodermic syringe has no 
equal. Dr. T. M. B, Cross, was the first, I believe, to use deep 
injections of morphine in sciatica. He has recommended that the 
point of the syringe needle be carried down to the sheath of the nerve, 
and the contents of the barrel gradually expelled. Strange to say, very 
few accidents have followed its use, although the wounding of an artery 
is not an impossibility. Chloroform has been used hypodermically by Bar- 
tholow,^ and with great success, and though I have produced abscesses 
in this way, I am inclined now to acknowledge its value as a therapeutic 
measure. Morphine, and atropine, ergotine, and other alkaloids are con- 
stantly used, and sometimes afford relief, which is generally temporary, 
but occasionally permanent. The general treatment, is however, all-im- 
portant, and iron, strychnine, arsenic cod-liver oil, and phosphorus 
rank high as valuable remedies. I have spoken of quinine. I may add 
that when given continuously, either in combination or alone, it cannot 
fail to do good. Tonga, the new Fiji remedy, has been recently recom- 
mended. It is excellent, especially in facial neuralgia, and may be 
given in doses of from ?tlx — rrj^xx every two hours until relief is obtained. 
Phosphorus always does good, except in forms of neuralgia, which are not 
directly dependent upon depraved nutrition, and are due to cold or at- 
tended by inflammatory conditions. Marey^ has recommended the nitrate 
of aconitia for facial neuralgia. He has cured cases very rapidly by the 
administration of a quarter of a milligramme several times a day, in- 
creasing the dose until the patient finally took as much as two milli- 
grammes. Gubler also used aconitia in facial neuralgia with much 
success. Dr. Sdguin some time ago called attention to its virtue in neural- 
gic affections of the fifth nerve. It should be given in doses of xioth of a 
grain, and repeated until the face becomes decidedly numb. The solution 
used by Seguin is as follows : 

R DuquesneFs aconitia gr. one-twelfth. 
Alcohol, 1 - - 2- • 

Glycerine, J ^ ^' 

Aq. menth. pip. ad ^ ij. M. 
Sig. : One teaspoonful three times a day. 

I have used it in the form of saturated tablets, prepared by Caswell, 
Hazard & Co. of this city. 

In cases of headache of the congestive variety it will be found that 



^ Mat. Medica and Therapeutics, p. 321, et seq. 
2 These de Paris, 1880. 



NEURALGIA. 537 

tincture of Cannabis Indica brought to the physiological point does much 
good. Thompson's solution is the best preparation.^ Salt air, with alter- 
nations of mountain air, nourishing diet, which should include a large 
proportion of non-nitrogenous food, attention to the daily habits, the 
removal of fecal accumulations, and the re-establishment of menstrual 
regularity are of the greatest importance, and should be accomplished if 
possible. 

R Phosphor! gr. ss. — iss. 
Alcohol absolut. q. s. ut. diss. 
Ess. menth. pip. q. s. 
Glycerinae ad. ^ iv. — M. 
Sig : A teaspoonful after eating. 



638 DISEASES OF THE PERIPHERAL NERVES. 



CHAPTER XVII. 

DISEASES OF THE PERIPHERAL NERVES (Continued). 

NEURITIS. 

Symptoms. — Inflammation of a nerve is expressed chiefly by sore- 
ness and tenderness, and not by darting or paroxysmal pain, which con- 
stitutes neuralgia. When confined to the nerve-trunk, various depraved 
conditions of sensibility, motility, and trophism may follow, which are 
expressed by cutaneous and muscular changes ; and the course of the 
nerve can usually be marked with great exactness, for pressure produces 
great pain. The skin may be red or the seat of bullous or peraphigous 
eruptions. Of course very much depends upon the character and impor- 
tance of the nerve aifected. Some of the nerves of sensibility, such as 
the fifth, when subject to neuritis, are followed by symptoms different from 
those which occur when the seventh or one of the mixed nerves is affected. 
Peripheral inflammation of the external portion of the seventh is often 
the cause of facial paralysis, and neuritis of the fifth may occasi(m disor- 
ders of sensibility as well as ulceration of the cornea and other trophic 
phenomena. With neuritis there is not infrequently loss of tactile sensi- 
bility and sense of appreciation of temperature, though in the beginning 
the skin is hyparaesthetic, and the pain is aggravated by contact with 
cold or hot substances. Erb speaks of acute and chronic neuritis, the 
former depending upon traumatism, sloughing, or cancer, and beginning 
with a chill, followed by fever, headache, and sleeplessness. The pain 
commences in the affected member, and extends, until finally chronic 
neuritis is progressive, the inflammation spreading, and involving new 
nerves. This extension may be recognized by the fresh appearance of 
pain in new localities ; by painful points (Valleix's) at new regions, by 
difference in the form of pain, and by variations attending pressure ; the 
whole limb is affected. This author, as well as Mitchell, considers that it 
is most intense at night, and that it is augmented by movement Mitchell 
has observed intense hysterical excitraent, and even delirium. A red line 
usually marks the course of the affected nerve, and there may be patches 
of herpes or pemphigus, or the skin may be oedematous. In one case, ob- 
served at the Epileptic Hospital, the patient, a negress, presented symp- 
toms of neuritis of the anterior tibial nerve, and the skin of the fore part 
of the right leg was tense, shiny, and exquisitely sensitive. A marked 
rigor ushered in its development, and there were subsequently nausea and 
vomiting Her pulse was feeble and rapid, and she could not sleep, and 
entirely lost her appetite. There was no inflammation whatever of the 
skin or muscular tissue, and the acute pain subsided in a few weeks, but 



NEURITIS. 539 

there remained a condition of great tenderness. Hot and cold applica- 
tions increased the pain. 

Paralysis may follow, and is by no means uncommon. The patient 
generally recovers in a month or so, and sometimes in a shorter time, but 
the neural condition never entirely disappears. In the chronic form the 
onset may be gradual or spontaneous, or follow an acute attack. I have 
sufficiently sketched the symptoms, and will only add that muscular 
cramps, tremor, or permanent contractures sometime? form very distress- 
ing sequelae, and with these there is paralysis. Ansesthesia or hyperses- 
thesia is connected with neuritis, the former being of late appearance. 
Erb calls attention to the comparative immunity of the motor nerves, as 
paralysis does not follow until after a long train of sensory disturbances, 
but reflex disturbances are not uncommon. These may consist in remote 
nerve pain, cramps of distal muscles, or hysterical attacks. The electric 
excitability in the early stages is exaggerated later, or it is lost, and if 
there be paralysis there is very marked muscular atrophy as a conse- 
quence, and electric contractility disappears altogether. By far the most 
interesting changes are those of a trophic character. Weir Mitchell has 
presented a most complete description of these structural alterations. 
The finger-nails lose their normal character, and become horny and curved, 
and the skin becomes rough and is sometimes exfoliated. 

As additional evidences of this defective nutrition, " hang nails," 
cracking of the skin and other slight changes from its healthy condition 
are striking indications. The illustration (Fig. 68) which I produce is 

Fig. 68. 




Trophic Change of the Skin. 

from the photograph of a patient whose hand had been anaesthetic for 
some years. The skin is hard, the palmar furrows are sharp and exag- 
gerated, and the bases are red or purple, somewhat reseoabling the same 



540 DISEASES OF THE PERIPHERAL NERVES. 

appearance in the cutaneous flexure of the knee, elbow, or other articu- 
lating parts in certain forms of chronic eczema. 

Causes. — The acute variety is dependent upon injuries of various 
kinds. I have seen one case which followed a carbuncle situated upon 
the inner surface of the forearm, and Mitchell reports several cases fol- 
lowing gunshot wounds. Flying splinters, fractures, and blows are 
various traumatic causes, while the extension of cancerous disease or 
sloughing may produce a neuritis. Cold, rheumatism, and syphilis enter 
into the etiology of the affection, and Mitchell has produced a neuritis 
by the local application of ice. In one case of facial spasm, for which I 
used the ether spray, I was disagreeably surprised to find a remaining 
neuritis of the portio dura, which lasted for some time. 

Beau has directed attention to forms of neuritis of the intercostal 
nerves which undoubtedly arose from pleurisy and pleuro-pneumonia. 
Typhoid fever, diphtheria, and other diseases of a febrile nature are not 
infrequently attended by neuritis, and in one case of typhus, reported by 
Bernhardt, a neuritis involved the musculo-spinal nerve. 

Morbid Anatomy and Pathology. — Inflammation of a nerve- 
trunk produces very decided changes in its appearance. It becomes 
swollen, is of a pinkish hue, and there is often an exudation which is 
found between the fasciculi ; this may be also of a reddish color. The 
microscopical appearance of the nerve is still more characteristic. The 
nerve-fibres undergo marked changes ; the axis, cylinder, and the medul- 
lary contents are disintegrated ; the neurilemma may be distended by 
serous exudation, and the blood vessels are enlarged and in places rup- 
tured, so that blood-elements may be found scattered in different regions. 
In later stages there may be atrophy or fatty degeneration. In chronic 
neuritis these appearances of advanced degenerative changes are found 
to consist in proliferation of connective tissues, and this takes place 
as an interstitial formation. Degeneration of the minute nerve-ele- 
ments, deposition of oil-globules, and sclerosed patches are found in old 
cases. 

If the inflammatory action be very severe, the nerve will be found to 
be completely destroyed by sloughing. The nerve may be found to be the 
seat of enlargements, which are to be seen at different localities in its course, 
and at each of these points there may be a diflTerent kind of change. In- 
flammation of a nerve-trunk, as I have said, is first attended by sensory 
changes, which may be local, or in other parts ; as the result of reflected 
irritability ; afterwards trophic changes may result either from the pro- 
duction of some pressure upon other parts, or through loss of function of 
the nerve itself. 

Diagnosis. — The limitation of the pain, its aggravation by pressure, 
its constancy, and its character, enable us to generally distinguish it from 
neuralgia. In chronic neuritis it is not so easy to make such a diagnosis. 
The painful points found in neuralgia may be mistaken for the sensitive 
spots in neuritis. I have seen very few cases in which the pain of neuritis 
was not constant, and this is not the case in neuralgia, which is essentially 



i 



NEURITIS. 541 

a paroxysmal disease. Painful swelling of the nerve and paralysis of 
muscles supplied are also evidences of neuritis, which will aid us in dis- 
covering the nature of the affection. 

Muscular rhei>matism has been spoken of by Erb as a condition with 
which the disease under consideration may be confounded. I consider 
such a distinction to be a refinement of diagnosis which cannot be made. 
"Muscular rheumatism" is, after all, a low grade- of diffused neuritis, 
and the most we can do is to discover the cause of such pain. 

Erysipelas, thrombosis, and embolism are distinguished by the evidences 
of subcutaneous swelling, oeedema, etc., and by their somewhat diffuse 
character. 

The presence of a traumatism should be taken into account, and its 
nature investigated. 

Prognosis. — Structural alteration of a nerve must follow an inflama- 
tion such as has been described, and unless the symptoms have been very 
slight, there is a tendency to continuance, so that an attack of acute neuritis 
assumes a chronic character. If the inflammation has advanced centrally, 
so that a new plexus is involved, the prognosis is very bad. Treatment 
has much to do in some cases with prognosis. 

Treatment. — To Mitchell we are indebted for excellent directions 
for the management of neuritis. He tried elevation of the leg or arm 
while bladders of ice were applied to every part of the limb, and is gr. 
hypodermic doses of atroj)ia, with i gr. doses of sulph. of morphia, were 
injected every four hours, or oftener. He has used leeches, so that con- 
siderable local abstraction of blood should take place. Perfect quiet is 
highly Important, and he recommends splints for the purpose. I have 
used the plaster bandage in a way to leave the course of the painful nerve 
exposed. The actual cautery is invaluable, especially when the disease 
is chronic, and it should be freely applied along the painful tract. Fara- 
dization does good, but I have no faith in the galvanic current, which 
only increases the pain. Hypodermics, either of morphia, atropia, or 
ergotlne, in the neighborhood of the painful point, may be continued for 
some time, with the effect of diminishing the pain and the violence of 
the inflammation. Large doses of iodide of potassium are of especial ser- 
vice ; and I have lately recommended inunctions of mercurial ointment 
with excellent results. This latter treatment is that which we are to 
employ when syphilis is suspected ; and the good effects are sometimes 
seen in a few days. As a dernier ressort nerve-section may be tried ; but 
if the neuritis has involved the nerve-plexus it does no good. It is only 
when a peripheral nerve is affected that it removes the disease. 

In nerve-stretching — an extremely valuable surgical procedure — we 
possess a means which promises to be of great service. The nerve is 
exposed, and forcibly pulled, so that the limb shall be raised. In one 
instance the portion of the lower extremity, including the leg and foot, 
was drawn up by the sciatic, which had been bared in its course down 
the thigh. 



542 DISEASES OF THE PERIPHERAL NERVES. 



ANJ5STHESIA. 

Symptoms. — An impairment or loss of cutaneous or muscular sen- 
sibility, either localized or extensive, may be the result of central disease, 
or it may be of a strictly peripheral nature. It is of the latter form 
that I now propose to speak. 

The anaesthesia may imply loss of the sense of appreciation of extremes 
of temperature, contact, or painful impressions. 

In the optic nerve, amaurosis is a result, and with this there is com- 
monly anaesthesia of the ciliary nerve, so that the influence of light pos- 
sesses no irritant effect. Deafness follows auditory anaesthesia, and loss 
of taste, anaesthesia of the lingual nerve. 

Anaesthesia and analgesia may exist alone or in complication, and we 
are constantly reminded of this state in cases where operations are per- 
formed on insensible parts, the individual only feeling the power of trac- 
tion or the contact of the surgical instrument. This is often observed in 
some of the uterine operations ; and DiefFenbach^ alludes to the anaesthetic 
condition produced by some of the agents employed, which only blunt 
sensibility, while the sense of contact still is preserved. I have myself 
witnessed this phenomenon in patients in whom local anaesthesia had been 
used. 

In regard to the measurement of sensibility, and its impairment by 
disease, I may state upon the autliority of Rosenthal,^ that the sensibility 
to tickling is the first to disappear, then to contact and pressure, and 
temperature, and finally to pain. 

In cutaneous anaesthesia a warm or cold body is not appreciable as such, 
but the individual can sometimes tell its shape, or feel the pressure made- 
A lump of ice is said to be irregular. The button of the heated cautery 
iron, if pressed against the skin, produces no discomfort, but only a sense 
of weight. The loss of tactile sensibility is generally abolished however, 
or greatly diminished. The patient will either not feel the points of the 
aesthesiometer at all, or, if he does, will be unable to tell how far they 
are separated. 

The local temperature and vascular supply are altered in many cas'^s, 
so that the warmth of the spot which has become anaesthetic is a degree 
or two below that of the sound parts adjacent. The vascular alterations 
are attended by bloodlessness and whiteness of the affected region. This 
diminished blood-supply of course invites pathological alterations of 
nutrition, for, when subjected to influences of temperature or injury 
which other normal districts would bear without damage, the anaesthetic 
skin becomes rapidly altered. Romberjii^ alludes to the occurrence of 
blisters and ulcerations which were readily caused during cold weather; 

1 Der J^ther gegen den Schmerz, 1847, p. 61. 

2 Clinical Treatise upon Diseases of the Nervous System. Am. Translation, p. 173. 
^ Manual of the Nervous Diseases of Man, p. 202. 



ANESTHESIA. 543 

and I have repeatedly seen the effects of injurious pressure, of surgical 
operations, and of the application of irritants. In one patient brought 
to me I was surprised to find an extensive ulceration of the skin of the 
forearm, which had resulted from the use of a stimulating liniment 
which the patient had used with the idea of improving an anassthetic 
state dependent upon rheumatism. 

Ancesthesla of the Fifth Pair. — This form of anaesthesia is commonly 
of peripheral origin, and of thirty-five cases collected by Ortel-Ebrard^ it 
resulted but nine times, from intracranial tumors. It is of spontaneous 
origin usually ; and the upper branch is most profoundly affected, so that 
the loss of sensibility is limited to the brow and region about the eye, by 
anaesthesia of the cornea, and consequent nutritive changes in that part 
of the optical apparatus. A case of this kind was reported by Dr. PI D. 
Noyes,'^ of New York, in which there w^as very decided sloughing of the 
cornea. The phenomena following ausesthesia of this nerve may be thus 
tabulated : — 

C Anaesthesia of upper eyelid 
Involvement of ophthalmic branch. -l and forehead. Irritating 

C substances are not felt. 

r Anaesthesia of middle por- 
Involvement of superior maxillary branch. I tion efface. Insensibility 

L of gums of upper jaw. 

f Anaesthesia of skin of lower 

I portion of face ; increased 
Involvement of inferior maxillary branch, j flow of saliva; mastication 

I difficult ; gums of lower 

i^ jaw insensible. 

The patient sometimes finds that the edge of the tumbler or vessel from 
which he drinks occasionally feels as if it were broken. Several of these 
cases are reported by Bell.^ In one of my cases the patient could not 
spit in a straight line, w^hile the secretion of saliva was quite abundant. 
This same patient complained that his gums were insensitive. These 
peculiar buccal and labial symptoms are generally early and prominent 
expressions. Sense of smell and sensibility of the nostrils and to^igue are 
lost when other branches are affected. A kind of anaesthesia, alluded to 
by Besuier, Rendu and others is that dependent upon venereal excesses 
and the pathological state is probably a lively spinal congestion. In a 
case reported by Besnier, there was some slight paresis of the lower ex- 
tremilies with analgesia, and pronounced loss of tactile sensibility. The 
patient was able to perceive temperature fluctuations. A cure followed 
six weeks of energetic treatment. 



^ Paralysie du Trijemeau, These Paris, 1867. 

2 N. Y. Medical Journal, 1871. 

3 The Nervous System, etc., 3d ed., p. 333, et t 



544 DISEASES OF THE PERIPHERAL NERVES. 

When the radial nerve is the seat of the peripheral trouble, it will be 
found that the back of the hand retains its sensibility. The lower ex- 
tremities may be affected when the condition is the result of pressure 
made upon the sciatic, and in the case of several skin-diseases the loss of 
sensibility may be general. Leprosy, syphilitic alopecia, and other skin- 
diseases may all be attended by loss of cutaneous sensation, which is the 
result of local dermal alteration of function. Bulkley^ has very ably 
considered this subject. 

In this connection it will not be amiss to refer to a form of anaesthesia, 
called by Raynaud " asphyxie locale des extremities,'^ which is commonly 
described as a vaso motor disorder. Nine years ago I presented cases, 
and Dr. M* Bride has since discussed the subject in a paper read before 
the Neurological Society. Through contraction of the arterioles, the 
fingers become pale, and there is a sharply defined local syncope. The 
fingers are anaesthetic, and the sense of appreciation of temperature is 
lost. The arterial contraction may be the consequence of a temporary 
spasm, or it may have a grave permanency, and be followed by gan- 
grene. The cases I have seen have been of short duration, and the 
subjects were women. The local syncope and anaesthesia is generally 
bilateral. 

The anaesthesia often remaining after diphtheria is one of considerable 
interest. It may, or not, be associated with paresis, but in either case 
the velum palati is commonly affected, and in many patients other 
parts of the body become anaesthetic. See^ reports an example in which 
the entire surface of the body was insensitive, the plantar surfaces even 
being affected, and, as a consequence, there was inco-ordination. This 
suggests the query whether the cases reported as locomotor ataxia of diph- 
theritic origin were not, after all, example's of plantar anaesthesia. 

Causes. — Cutaneous anaesthesia may be due to pressure made upon, 
a nerve-trunk in its course, or to the compression of peripheral areas of 
greater or less extent, or to local impairment of function by exposure to 
cold, to certain chemicals, or to like agents ; while general diseases, such 
as syphilis or rheumatism, by local disease and infiltration, greatly alter 
the function of cutaneous nerve-filaments. The toxic effects of lead 
shown in abolition of cutaneous sensibility were pointed out by Beau* in 
1848. In 38 cases analyzed by him, loss of tactile sensibility was de- 
tected not only in skin of the forearm and arm, but in parts lined with 
mucous membrane, the pharynx and the interior of the nose. Intense 
cold, liniments which contain aconite, or long immersion of the hands in 
fluid of any kind, will result in a loss of sensibility. One of my patients 
was a dyer, whose hands were kept in warm dye-liquids for many hours ; 
and some of the French writers give examples of the disease among 

1 The Eelations of the Nervous System to Diseases of the Skin. Archiv. of Elect, 
and Neurology, 1874-5. 

2 Gaz, Med. de Paris, 1864. 

3 K^cherches sur I'anesthesie, Archives. Gen. de Med., 1848. 



ANESTHESIA. 545 

washerwomen. Alkaline fluids are more favorable to its production than 
any others. Tight splints, blows ; diphtheria and other acute maladies, 
hysteria, and several other conditions play a part in its etiology. 

Diagnosis. — Peripheral anaesthesia must be diagnosed from the cen- 
tral condition, and it is necessary that we should bear in mind not only 
the anatomical arrangement of the nervous supply, but the coexistence or 
absence of symptoms of central disturbance. Among the latter are loss 
of power, which usually accompanies the anaesthesia, or one or more of 
the many symptoms previously alluded to. 

Trigeminal anaesthesia is, perhaps, more difficult to trace out than that 
of other nerves. Romberg^ thus enumerates the indiqations of anaesthesia 
of peripheral or central origin : — 

" a. The more the anaesthesia is confined to single filaments of the 
trigeminus, the more peripheral the seat of the cause will be found to 
be. 

" b. If the loss of sensation affects a portion of the facial surface, to- 
gether with the corresponding facial cavity, the disease may be assumed 
to involve the sensory fibres of the fifth pair before they separate to be 
distributed to their respective destinations ; in other words, a main 
division must be affected before or after its passage through the cranium. 

" G. When the entire sensory tract of the fifth nerve has lost its power, 
and there are at the same time derangements of the nutritive functions in 
the affected parts, the Gasserian ganglion, or the nerve in its immediate 
vicinity, is the seat of the disease. 

" d. If the anaesthesia of the fifth nerve is~ complicated with disturbed 
functions of adjoining cerebral nerves, it may be assumed that the cause 
is seated at the base of the brain." 

Prognosis. — It is by no means bad after the cause is removed. 
Anaesthesia from pressure is rapidly restored, provided the mechanical 
injury be not too great. If there be division of the nerve, the process of 
reparation, which rarely extends for more than a few months, is followed 
by a healthy return. With syphilis and metallic poisoning, and skin dis- 
eases the case is different. 

Treatment. — Electricity offers the best mode of relief. The wire 
brush and faradic current are to be employed every day ; and at the same 
time applications of alternate heat and cold, friction and massage, are 
useful adjuvants. 

1 Romberg. A Manual of the Nervous Diseases of Man. Sydenham trans., vol. 
i. p. 213, etseq. 

35 



546 DISEASES OF THE PERIPHERAL NERVES. 



TUMORS OF NERVES. 

Synonym. — Neuromata. 

A nerve may be the seat of either a syphilitic, cancerous, sarcomatous, 
myxomatous, or other growth which may involve or destroy some point 
in its continuity, or form as a benignant tumor at its point of severance. 

Very little has been written on this important subject ; but among the 
most valuable contributions to the literature of nerve-tumors is an excel- 
lent thesis by Foucalt,^ and various scattered articles by Verneuil,^ Le 
Fort, Axenfeld, Roger, and others. 

Nerve-tumors may be classified as neuromata (nervous neuroma of We- 
ber) and medullary nerve-tumors, which involve the nervous structure 
itself; and pseudo-neuromata, yvhich include the fibromata, myxomata, 
epithelioma, as well as cysts and tumors of alike character. 

Medullary or ganglion tumors are quite rare, and are of a hyperplastic 
character. Lebert ^ described a neuroma of the superior cervical ganglion, 
in which all traces of true nervous matter had disappeared, and naught 
remained but a fibro-fatty structure. Robin* has found a neuroma in the 
solar plexus, and Virchow has also brought forward examples. 

Neuroma of nervous fasciculi {nevromes fascicules) include the little 
painful tumors which are met with after amputation, which give rise to 
stump neuralgia, and attain the size often of a hazel-nut. Diipuytren,^ 
Cornil^ and Ranvier, Axmann^ and Weissman,^ have all described their 
appearance and structure, which is fibrous and hard, and the nerve tubes 
are tortuous and interlaced. 

The pseudo-neuromata are of many varieties. They are developed 
usually in the course of the nerve, and the neurilemma is thickened, and 
should the nerve be cut across, a white or yellowish hardening will be 
presented. Should the tumor be fibrous, the peculiar microscopical ap- 
pearance may be observed. Fibromata rarely exceed the size of an 
almond ; but when there is any fluid found, as in the case of fibro-cystic 
tumors, the volume of the enlargement may be much greater. 

The accompanying cut represents a sarcoma of the ulnar nerve, and 
was observed by Demarquay at the Maison Municipale de Sante. 

Nerve-tumors prefer the nerves of the upper and lower extremities, and 
in the leg the posterior tibial nerve seems to be a common site. It is not 
uncommon to find a great many tumors of this kind existing at the same 
time. In one case reported by Foucault, 1400 of them were found, but 

1 Sur \e^ Tiimeurs des Nerves Mixtes, These de Paris, 1872. 

^ Arch, de Me;l., torne xviii. 1861. 

3 M€!n. de la Soc. de Clin. 1853, 3 fasc. 

* Comptes Rendus de la Soc. de Biol., 1854. 

^ Loc. cit. 

e Meiuoires de la Soc. Biologie, t. v., 3d Bine, 1863. 

1 Beitrage zur. mikr. Anat. du Ganglion Nervensysteras, Berlin, 1853. 

^ Ueber Nerveanenbildung (ZjiUchr. f. Rationelle Med. 1859.) 



TUMORS OF NERVES. 



547 



Fig. 69. 



this is exceptional, and it is probable that multiple neuromata are more 
frequently found in patients who are of the cancerous, syphilitic, or some 
other diathesis. Very often these growths, the result of injury, are sub- 
cutaneous. In one of my cases the growth was found at the elbow at the 
exposed site of the ulnar nerve, and its origin followed a blow upon that 
part. 

Pain, as I have said, is the prominent symptom of such growths. This 
pain may appear upon the tumor, but usually follows its 
establishment. It may be localized or diffused, or may 
be provoked by pressure on the spot or spots which mark 
the site of the growth ; for, when the tumors are multi- 
ple, of course the sensory troubles are equally numerous. 
The pain may radiate from the tumor, or may dart down 
or up the affected nerve. It is not so intense with fibro- 
mata, syphilomata, or sarcomata, or when the tumor is 
composed mainly of true nervous tissue, as is the case in 
stump growths, and in these examples it is productive of 
severe neuralgia of a reflex character. Spasms, perma- 
nent muscular contractions, and sometimes a peculiar con- 
striction of the thorax of a tetanic nature, with epilepti- 
form seizure and centripetal pain, are indicative of certain 
reflex dl-turbances. 

Treatment. — Operation seems to offer the only hope 
of relief, and in stump neuromata re-amputation is often- 
times necessary. It will be found necessary to deeply 
anaesthetize the patient, as the sensibility is so morbidly 
active that ordinary anaesthesia is insuflicient The re- 
moval of a considerable piece of the nerve is advisable, 
for it is not rare to find considerable infiltration or deposit 
in its substance for some distance from the actual growth. 
In syphilis, mercurials and the iodides offer some show 
of relief, and these are the only remedies when the 
growth is deep-seated. Legrand ^ and others have recom- 
mended caustic applications in superficial regions, and Sarcomatoilf 
Sitbald pere removed a tumor in this way from the an- ^''^^' ^^^^^^^^) 
terior tibial nerve. The operation is rather severe, and is attended with 
doubtful success. 




Neu- 



Gaz. MeJ., Coiupte-Rendus de I'Acad. des Sciences, 1858. 



548 DISEASES OF THE PERIPHERAL NERVES. 



CHAPTER XVI T I. 

DISEASES OF THE PERIPHERAL NERVES (Continued). 
LOCAL PARALYSES. 

FACIAL PARALYSIS. 

Synonyms. — Bell's paralysis ; Histrionic paralysis. 

Facial paralysis may be either double or single, but is more often the 
latter ; and it may depend upon a lesion of a peripheral kind, or one that 
may be seated in the temporal bone, or at any point in its course within 
the cranial cavity, or else at its origin. 

The bilateral form is rare, and is always the result of a central lesion ; 
but the peripheral form is unilateral, and is a very common affection. 

Symptoms. — The patient, after exposure, may suddenly be attacked ; 
and the first intimation he generally basis in the morning, when he arises. 
He then finds his face to be all awry, and his appearance is absurd to the 
last degree ; one side being drawn up, Avhile the other is immobile, as the 
muscles of expression are powerless. If he laughs, the contortion is more 
marked, and if he attempts to whistle he will find that he is utterly una- 
ble to do so. The corner of the mouth on the sound side is drawn up, 
and the furrow at the angle of the nose is more marked than natural. 
The opposite side of the face is smooth; and, in the passive state, the 
muscles seem to sag heavily downwards. It is impossible for him to cor- 
rugate his eyebrows ; and the eyelids of the paralyzed side cannot be 
closed, so that dust and foreign substances collect, producing irritation 
and discomfort. This is due to the paralysis of the orbicularis, and at 
the same time the levator palpebrarum contracts and keeps the eyeball 
exposed. The individual is unable to blow out a candle, and articulation 
is interfered with to a slight degree. Should he be an old man, any 
wrinkles or furrows that may have existed on the paralyzed side are ef- 
fectually effaced, and give that part a most ghastly appearance. Consid- 
erable discomfort results from the insufficiency of the lower lid, so that the 
tears, instead of being conducted to the lachrymal canal, find their way 
over the cheek. 

If the lesion be situated within the temporal bone or the cranium, a 
much more extensive paralysis may result. This is indicated by a loss of 
power of the muscles of the palate, uvula, and other parts of the fauces. 

When the patient opens his mouth, the palatine arch will be found to 
be altered, the anterior pillars of the fauces being shorter, so that one side 



FACIAL PARALYSIS. 549 

falls lower than the other.^ The uvula will also be found to be arched, 
the concavity looking towards the sound side. The tongue will then also 
be paralyzed, so that its surface is smooth ; and there may be a dryness of 
the mouth, which results from diminished secretion of saliva. Should the 
portio mollis be affected, there may be, in addition, deafness. If the 
third nerve be afiected, as it sometimes is, of course ptosis with dilated 
pupil and paralysis of the recti will result. 

Roux,^ who was paralyzed in this manner, perceived a metallic taste in 
the right side of the tongue. 

Should the paralysis be bilateral, the patient's features will denote an 
entire lack of expression, and there is not the slightest evidence of any 
emotional excitement expressed, even should the patient be agitated by the 
most intense pleasure or the deepest grief. The muscles are flabby, and 
the face seems more like a mask than what it really is ; and, as is the case 
in advanced progressive muscular atrophy, the only animated features are 
the eyes. 

Romberg^ describes the appearance of a patient in these words: " In a 
girl of 16, in Dupuytren's Clinique, who was affected with bilateral para- 
lysis, there was no distortion, but a pendulousness and entire absence of 
motion was perceptible in all the features. The eyelids only closed half, 
the lips stood apart, and played backwards and forwards from the impulse 
of respiration. The expressive countenance bore a serious character, which 
contrasted forcibly with the patient's frame of mind. She was heard to 
laugh aloud, but the laugh appeared to comeirom behind a mask." Sensa- 
tion is not usually impaired. 

Causes. — The peripheral, form of paralysis may follow exposure to 
cold, rheumatic exudation, and injuries of various kinds. A cause which 
is frequently observed is the chilling of the face by a blast of cold wind ; 
and the frequency of this cause has led to the adoption by the French 
writers of the term, " Coup de vent." I have met with many cases in 
which the paralysis took place after a railroad journey, the individual hav- 
ing sat by an open window. 

In one instance the patient, who was a young lady, had been dancing 
violently, and had afterwards gone into a damp conservatory to cool off; 
the palsy was shortly afterwards noticed. 

Rheumatic exudations may produce pressure upon some of the nerve- 
twigs, or an attack of parotitis may result in pressure upon the cervico- 



^ Hughlings Jackson {London Lancet, J a.n. 16, 1875) does not consider that devia- 
tion of the palate occurs in uncomplicated disease of the portio dura, and he does not 
believe deviation of the uvula to be uncommon in healthy people. Troltsch says that 
the levator palati is supplied by the vagus, which explains the phenomena witnessed 
by Jackson, viz., marked palsy of one side of the palate, with palsy of the vocal 
cord on the same side, as a result of intracranial disease. This case, however, is ex- 
ceptional. 

2 Descot. Diss, sur les Affections locales desNerfs, Paris, 1825, p. 331. 

^ Op. cit., vol. ii. p. 268. 



550 DISEASES OF THE PERIPHERAL NERVES. 

facial branch. Injuries of the nerve, whether such as follow coarse trau- 
matism or accidental section of the nerve during a surgical operation, are 
sometimes the cause of the paralysis. 

Weir Mitchell relates several cases of this kind. Three of these 
(Cases 61, 62, and 63) followed gunshot wounds.^ In one the portio dura 
of the left side was injured, and as a consequence there were facial palsy, 
impaired speech, and loss of gustation. Hearing was impaired from 
shock transmitted to the auditory nerve. Sir Charles Bell ^ divided the 
facial in removing a tumor, and other cases are reported by various sur- 
geons. 

Carious disease, as well as fractures of the temporal bone, often produces 
paralysis, either by pressure, by the products of inflammation, or by di- 
rect contusion. 

Tumors and various aural growths are occasionally causes of this second 
form of facial palsy; aud Romberg^ reports a case, seen by Henle, in which 
a tuberculous deposit was found beneath the middle lobe of the brain, 
with destruction of the petrous portion of the temporal bone ; and Fro- 
riep* also found a deposit of tuberculous matter in the Fallopian canal, 
with caries of the petrous portion of the bone. 

Degeneration, exudation, and tumor in or near the pons may also be the 
cause of the deep form. 

The following case is an example of deep-seated paralysis, evidently 
dependent upon aural disease : — 

Samuel M., aged 27 ; United States, canal boatman; came to me July 
3, 1876. Three days before the first visit, after exposure while washing 
the decks of his boat, he became paralyzed. He had had earache before 
for several days, but did not consider it of sufficient moment to quit work; 
and his first intimation of trouble was the discomfort produced by parti- 
cles of dust which blew in his eye. He could not close his left eye, and 
on looking in the glass he discovered the paralysis. There was no pain, 
nor any subjective sensation of any kind. He found that he could not 
laugh, nor blow his nose, and when he attempted the latter *' the wind 
came out of his mouth." When I saw him there was paralysis of both 
branches of the seventh nerve. Hearing was very imperfect, and he could 
not count the ticks when the watch was pressed to the left ear. The left 
palatine arch was obliterated, and he could not fully protrude the tongue, 
which was quite dry. The left side of the face is quite flat, and the mus- 
cles of the other side act to such a degree as to draw up the right corner 
of the mouth, producing the characteristic deformity. When he opens 
his mouth the orifice is unsymmetrical. He cannot whistle or expecto- 
rate, he cannot close the left eye, but when he attempts to do so the ball 
is drawn upwards, so that the sclerotic is shown to a great extent. Con- 
tractility to both currents fair ; mediate and immediate galvanization are 
followed by muscular response. He has some earache. When the elec- 

1 Injuries of Nerves, etc., p. 392, et seq. 

2 The Nervous System of the Human Body, 3d ed., 1836, p. 56. 

3 Romberg, op. cit., p. 272. 

* Massalien, Diss. Inaugur. de Nervo Faciali, Berolini, 1836. 



FACIAL PARALYSIS. 551 

trode is passed over the superficial points of the fifth, there is decided 
pain, no anaesthesia; force of raasseter muscles tested by putting the dyna- 
mometer bulb between the teeth and interposing two pieces of wood ; no 
loss of power as compared with my own attempts. Tympanum congested ; 
and I infer that there is middle ear disease. R. Potass, iodid. and syring- 
ing ear with warm water. 

July 6. Has had intense pain in the left ear, throbbing and pains which 
radiate over the head. Pressure over mastoid process gives great distress, 
as does electrization. Leeching to inner tragus. 

9/A. Says that there was a discharge of pus last night. After syringing 
out I find a perforated tympanum. Stopped iodide, and ordered syring- 
ing with \varm water and glycerin. 

13^/t. Discharge from ear much less. Used iodoform powder locally. 
Muscles do not respond so well to eiiher current. Iodide renewed. 

11th. ISo response to current. Faradized nevertheless. 

l):}th, 2\d, 236?, Tlth. Used iodoform. Aural disease almost well, but 
patient still deaf. Muscles still inactive. 

30^A. Tested sense of taste, and find it markedly affected; his tongue 
seems quite smooth. He has had from the first some clumsiness in 
speech. 

Oct. 1877. There has been very slight improvement since the last entry. 
The facial deformity is not so ^reat. He is still deaf. His speech is clear, 
but he cannot whistle as yet. The muscles do not respond to the currents. 
He suffers great annoyance from the accumulation of saliva, and when he 
expectorates he soils his clothing. 

Pathology. — The anatomical distribution of the facial nerve, and its 
connection with other nerves may be referred to in illustration of the pa- 
thology of the affection. Beginning externally, we find that the facial 
nerve supplies the muscles of the face, the malar branches innervating the 
orbicular muscles of the eyes ; that the infra-orbital supply the buccina- 
tor and orbicularis muscles, and the levator labii superioris alseque nasi 
muscles; while the cervico-facial division of the nerve passes through the 
parotid gland, and supplies the muscles of the mouth and lower jaw; 
consequently a lesion of any of these branches, or of the main trunk at its 
exit from the stylo-mastoid foramen would be followed simply by paresis 
of the facial muscles. Should the lesion take place in the aqueductus 
Fallopii, or behind the geniculate ganglion, we would find as a conse- 
quence paralysis of the muscles of the face, the tongue, through paralysis 
of the chorda tympani, and paralysis of the palate muscles, through para- 
lysis of the larger superficial petrosal nerve, which runs from the genicu- 
late ganglion to the spheuo-palatine ganglion. Deep lesions may involve 
the third nerve, and perhaps the sixth. The lesions and their results may 
be thus arranged : — 



552 



DISEASES OP THE PERIPHERAL NERVES. 



Paralysis of the Seventh Nerve, 



EXTERNAL THIRD. 



Facial Branches. 



Paralysis of the 
Orbicularis palpebrarum) 
Corrugator supercilii, 
Levator labii, etc., 
Pyramidalis nasi, 
Diagastric, 
Buccinator, 
Orbicularis oris, 
Depressor anguli oris, 
Levator labii inf. 



MIDDLE THIRD. 

Petrostal nerves, Auditory 

(Portio mollis), Chorda 

' Tympani. 

Paralysis of all the fore- 
going as well as lingualis, 
tensor and laxator tym- 
pani, levator palati, and 
azygos uvulae. 



INTERNAL THIRD. 

Possibly lesion involve 
the 3rd and 6th nerves, and 
then besides all of the fore- 
going there may be paraly- 
sis of the levator palpebrae 
and the recti muscles. 



Diagnosis. — The appearance of facial paralysis may be a source of 
alarm to the individual, who is ready to believe it a feature of cerebral 
hemorrhage or deep organic trouble. It is much more profound, however, 
than the form which accompanies cerebral hemorrhage ; and generally 
there is hemiplegia of the extremities in the latter disease. In this form 
it is impossible for the patient to shut the affected eye, while in the other 
disease there is usually no difficulty in so doing. Sensation is also affected 
in the paralysis from cerebral hemorrhage, and it is not unusual to find 
ptosis. The matter of importance, however, is the diagnosis of the 
variety of facial palsy, superficial or deep : and we may avail ourselves 
of electricity in settling this point. 

If the paralysis be peripheral, the muscles retain their contractility 
for several weeks. If, on the contrary, the lesion be central, or in a 
nerve-trunk, they lose their power of response to a faradic current in a 
few daysj and later to even a galvanic current, and the muscles finally 
become atrophied. If the paralysis be due to bulbar disease, the appear- 
ance of symptoms indicating impairment of other nerves and an eventful 
fatal termination should settle the nature of the affection, and enable us 
to make a prognosis. The existence of carious disease and its indica- 
tions, the complication of deafness, and the co-existence of indications of 
deep trouble, should be all taken into account. 

Prognosis. — The prognosis of the peripheral form of the disease is 
very good, and under proper treatment the paralyzed muscles may be 
rapidly restored. There is generally early loss of muscular contractility, 
which only the galvanic current can restore. If there is no response to 
electrical excitement, and the muscles of the paralyzed side are wasted 
and contracted, there is little to be hoped for. I consider that more de- 
pends upon the early adoption of electrical treatment than anything else ; 
and if there be a delay in the selection of remedies, and in the attempts 
to restore the muscles by mechanical support and electricity, the progno- 
sis, which may have been favorable in the beginning, becomes less and 
less so, the longer action is delayed. 



FACIAL PARALYSIS. 553 

Syphilis is a favorable element if the paralysis be due to deep lesions ; 
but, if it be caused by brain-tumors, exudations, or degeneration, there is 
scarcely any hope. 

Treatment. — It is necessary in this .disease to direct the treatment 
not only to the cause, when one can be found, but also to the restoration 
of the paralyzed muscles. 

Should rheumatism exist, we are to employ colchicum and iodide of 
potassium ; if syphilis, the specifics which are at our disposal ; and if 
there be caries, we are to improve the patient's general health by nour- 
ishment and stimulants, and to apply such local treatment as may seem 
proper. The medicaments which will be found to be of service for the 
direct treatment of the paralysis are strychnia, iron, and quinine. Elec- 
tricity is of great service ; and we may begin with the galvanic current 
and use the faradic as soon as it can produce contractions. The negative 
pole of the galvanic battery should be placed behind the ear, and the 
positive pole passed over the different facial muscles. The glass " bain 
^lectrique " should be applied to the eye, so that the orbicularis shall be 
brought under the influence of the current. 

The mechanical treatment of facial paralysis has been advocated by 
Detmold, and with admirable results. A piece of tin wire is bent at both 
ends (Fig. 70), and one end is passed over the ear and the other hooked 
in the angle of the mouth, so that the muscles of the paralyzed side shall 
be supported. In several of Detmold's cases it was found to work ex- 
ceedingly well. 

Fig. 70. 




Wire Hook for the Treatment of Facial Paralysis. 

This apparatus may be worn at night or during the day, and does not 
give the patient any discomfort whatever. 

Dr. Van Bibber has suggested, in the treatment of ptosis, the use of a 
small strip of court plaster, which is affixed to the upper lid and to the 
forehead above. 

I may append a case of facial palsy of a syphilitic nature cured by 
electricity in a remarkably short space of time. 

W. O. I., 30 years ; United States, boatman. Previous history : He 
has never been seriously ill, but ten years ago he had a chancre, followed 
by marked secondary symptoms. The only other ailment was a severe 
attack of rheumatism, occurring a year before. This was undoubtedly a 
secondary symptom. His present difficulty began three months ago. At 



554 DISEASES OF THE PERIPHERAL NERVES. 

night he was disturbed by intense cephalic pains, dizziness, and disordered 
vision. For several days the pains were steady and most violent under 
either temple ; he was also annoyed by post-aural pains. He then found 
that his hearing was becoming less acute,, till the lesion finally occurred. 
This took place toward the latter part of July, 1880. He awoke in the 
morning and felt a pain in the head, attended by swelling and puffiness in 
the face. His attention was called by several of his associates to the 
" crookedness" of his face. He looked in the glass, and saw the drooping 
of the left side of the face, with complete paralysis of the muscles at the 
corner of the mouth ; then followed total loss of hearing, and he could 
not appreciate the loudest noises when the sound ear was closed. The 
paralysis increased every day. 

A few days after this the eyelid drooped, and he found it impossible to 
open or completely shut the eye. It became congested and irritated, and 
he experienced a burning sensation with photophobia. His condition 
grew gradually worse, till he was compelled to leave his employment and 
seek medical aid. He never had had otorrhoea or ear affections of any 
kind, nor had been paralyzed. His habits were good, and his hereditary 
history favorable. When he applied to me, I found paralysis of the entire 
seventh nerve, motor ocularis, and disturbance of the sympathetic of the 
eye. There was no appreciable power in the orbicularis oris, levator 
labii superioris et alseque nasi, or other muscles. He could hardly insert 
the finger in the mouth without pulling down the jaw with the other 
hand. He experienced mastication and deglutition from involvement of 
the left side of the tongue, which, when protruded, inclined to the right 
side. With this there was indistinct articulation, and I was led to infer 
paralysis of the lingualis muscle. From the patient's previous history I 
was led to suppose that syphilis was the primary cause of the trouble, and, 
from the depth of the lesion, that the seventh nerve was paralyzed at a 
point above its division From the specific features of his case I deemed 
the iodide of potassium to be the best remedy, and he was therefore put 
upon grs. V thrice daily. Hypodermic injections of strychnia and atropia 
did much good in relieving the severe cephalalgia. Localized galvan- 
ization was resorted to, and both the primary and secondary currents 
used. After the nerve and its branches had been pencilled over 
with stick caustic, one electrode was applied to the ramifications 
of the nerve, while the other was placed over the mastoid process. So 
successful was this treatment that after a daily seance lasting twenty 
minutes, in three weeks the patient's face was much more symmetrical, 
and the act of mastication improved. The pains like wise disappeared 
under the same current. Occasional directions of this and the fara- 
dic current over the eyelid did much toward the improvement of 
sight. 

It now occurred to me that Matteucci's experiment on the ear might be 
followed by gratifying results; so its cavity was filled with water, and one 
of the 'battery-wires, finely covered with sponge, was gently introduced 
into the external meatus. After four weeks his hearing was so markedly 
improved that he easily distinguished loud voices when the sound ear was 
closed. 

November 12 (seven weeks after commencement of treatment). During 
the application of the current the face resumed its expression, and he was 
able to close his eye completely. He is greatly improved; injections dis- 
continued. He has almost complete control over the levator palpebrse — 
this is marked in the morning ; articulation good. 



TRAUMATIC PARALYSIS, 555 

28th. Has now taken the battery for nearly ten weeks, and is about 
to discontinue treatment. The face is perfectly symmetrical, and the 
hearing nearly as perfect as ever. The only remaining disfigurement is a 
slight drooping of the eyelid on the affected side ; appetite good, and, 
though emaciated at first, he has now completely regained his former healthy 
condition. 

TRAUMATIC PARALYSIS. 

Under this head I propose to speak of those forms of lost power de- 
pendent upon partial or complete nerve-section, or pressure made upon a 
nerve in its course, such as is often seen in a familiar form known as 
decubitus paralysis, as well as in the loss of motility produced by cold or 
other influences which may affect the ramifications at the peripheral end 
of a nerve-trunk. There is no regularity either in the form of invasion, 
the extent of the paralysis, or its locality. Suffice it to say, that both upper 
and lower extremities maybe affected, the upper especially, and that such 
paralysis is not bilateral. The liability of the upper extremities to this 
accident is probably explained by their use in many of the necessary 
actions of everyday life. These forms of paralysis may be divided into 
three groups : (1) Paralysis following section or destruction of a nerve- 
trunk or its branches ; (2) Paralysis following pressure ; (3) Paralysis 
following cold, or general disease. 

Division of a Nerve-trunk. — If the section be complete, the paralysis 
will be equally complete and immediate. There is likely to be, in addi- 
tion to lost sensation and motion in the muscle supplied by the nerve, 
various trophic defects, which may consist in exfoliation of the skin, 
and in changes in the condition of the nails, which become curved, cre- 
nated, and deformed ; and sometimes eruptions. Th^ loss of motion, of 
course, will depend upon the importance of the group of muscles supplied 
by the nerve ; and it does not follow, by any means, that th§ member is 
utterly useless, as some muscles may escape the paralysis. Should sup- 
puration and inflammation occur at the wound, there may be various dis- 
turbances of sensation, and also lowered temperature in the paralyzed 
side. 

Contusions and Pundured Wounds. — The injuries produced by kicks, 
or direct violence, when the skin is not broken, are very commonly fol- 
lowed by traumatic paralysis. These are likely to occur when the nerve 
rests upon some bony prominence, and when there is no muscular or other 
cushion to make the blow less slight. I can recall cases of this kind, 
one in particular, where the individual fell in the street, striking his elbow 
upon a projecting stone. There were no immediate symptoms except a 
tingling and sharp pain, but in a fdw days there was loss of power, and 
some hypersesthesia of the forearm. 

The experience of surgeons furnishes us with numerous examples of 
peripheral paralysis from dislocation. Dr. S. G. Webber,^ of Boston, has 
brought forward several very interesting cases of this variety, with dislo- 

1 Boston Med. and Surg. Journal, Dec. 18, 1873. 



556 DISEASES OF THE PERIPHERAL NERVES. 

cation of the humerus ; and Onimus and Legros^ a case which Webber 
presents in his article to illustrate a form of paralysis following disloca- 
tion of the femur : — 

" A man, forty-six years of age, suffered an ilio-ischiatic dislocation of 
the femur, which was produced by violence exerted by falling rocks and 
earth. Severe pain, ansesthesia, and immobility of the leg existed at 
first, but the pain subsequently disappeared, and the ansesthesia remained. 
After an attack of facial erysipelas the pain in the legs returned. Five 
months later the left leg was found to be cold and smaller than the other, 
and oedematous about the tibio-tarsal joint. The leg could be flexed and 
raised, but the foot could not be raised nor the toes extended. Sensation 
w'as diminished, as was electro-muscular contractility, especially in the 
flexors and extensors of the leg, the muscles of the calf and the peronei, 
as well as the tibialis anticus and extensor communis." 

In Webber's case of paralysis following dislocation of the humerus, the 
biceps and deltoid were most affected, and there was ansesthesia over the 
deltoid. 

J. S. came to the N. Y. State Hospital for Disease of the Nervous Sys- 
tem, June 9, 1871, with the following history : During an altercation 
with a fellow-laborer he was thrown off a scaffold, and dragged by his 
right arm for some distance. When he arose he found that the whole 
arm was very painful, and a few mornings afterwards the right wrist be- 
came very weak, and he was unable to grasp any object or move his fin- 
gers. Sensation was unimpaired. 

Nerve-injury following dislocation is not always the same, there being 
in some cases simply pressure, and in others rupture of the nerves by 
strain ; and of course the prognosis depends much upon the fact whether 
there be simple contusion or actual laceration, as there was in a case re- 
ported by Hilton. 

Pressure upon nerves may be made by the products of inflammation, 
ci( atrices, callous tumors, or by improperly arranged splints, or the pres- 
sure of a crutch or some hard substance, or by the maintenance of a con- 
strained position for an extended period. The products of a periostitis 
may exert pressure upon a nerve-trunk, or an exudation which makes com- 
pression either in its course or at its ramification, may either account for a 
paralysis. There is always some painful indication at first, and occasionally 
a neuritis, after which the loss of power takes place. Movement of the limb 
aggravates this pain, or pressure over the nerve has the same effect. 
Pressure from a cicatrix is quite rare, and it is only when very extensive 
contraction of the cicatrix occurs that any such condition of affairs can 
exist. So, too, is pressure from callus an uncommon cause of paralysis, 
and but a few cases of this kind have been mentioned. 

The pressure of the nerve by a tumor may be first indicated by hyper- 
sesthesia, and secondarily by loss of motion and sensation, and the dura- 
tion of the first stage depends upon the site of the tumor, its rapidity of 

1 Traite de I'Electricite Medicale, Paris, 1872. 



TRAUMATIC PARALYSIS. 557 

growth, and tlie room for increase in size. In certain situations where 
there are bony eminences or cavities, and where there is no room for ex- 
pansion of the mass without consequent nerve-compression, the loss of 
function is very quickly produced. 

By far the most familiar form of peripheral paralysis is that which fol- 
lows the compression of nerves daring the continued maintenance of a 
constrained position, the nerve-trunk being pressed against some bony 
eminence, or impinged upon by some tendon or muscular mass. The 
musculo-spiral nerve is, from its exposed position, most commonly af- 
fected. The common modes of onset may be the following: The patient 
falls asleep with his elbow resting upon some hard substance, and 
awakens to find his forearm devoid ot power, so far as extension is con- 
cerned. There is some anaesthesia as well. The following are ex- 
amples : — 

M. P. went upon a spree, and when he became sober found his arm 
numb and cold, and devoid of power; muscles respond to faradic current; 
unable to force dynamometer column to 6. 

T. W., four years ago, fell asleep with his left arm under his head ; 
when he awoke his arm was numb and powerless. Soon after formica- 
tion appeared. After seven months, pain, which subsequently became 
paroxysmal, began in the arm, coming on every two or three minutes. 
Response only to galvanic current. 

In one case, reported by "Webber, the paralysis was the result of carry- 
ing a basket of lemons, pressure being made On this nerve. 

MitchelP speaks of paralysis of this kind resulting from the most 
simple causes. In one case, that of a child, pressure was made by a string 
passing over the finger. And in other cases reported by Brinton,* it was 
found that the paralysis followed the rough use of a pair of cord handcuffs 
upon a prisoner who was being taken to the police station. 

The use of the forceps is occasionally attended by paralysis of the 
facial nerves, the blades of the forceps making pressure upon the portia 
dura. In these cases there is paralysis of the facial muscles, an inability 
to nurse owing to the paralysis of the orbiculaiis oris, but no palatine 
loss of power, which serves to diagnose the effects from the form due to 
intracranial trouble. The mother may be paralyzed from pressure by 
the forceps exerted upon the pelvic nerves, but this accident is an ex- 
tremely rare one. 

Accumulation of feces produces paralysis generally by reflex irritation, 
and rarely by direct pressure. But few of such cases have been reported, 
and of these, one detailed by Portal ' is of great interest, from the fact 
that spinal curvature favored the accumulation of feces and the exertion 
of pressure upon the nerves of the lumbar plexus. 



1 Op. cit., p. 126. 

^U. S. San. Com. Reports. 

^ Cours d'Anatomie MeJicale, t. iv. p. 276, quoted by Mitchell. 



558 DISEASES OF THE PEKIPHERAL NERVES. . 

Cold or malaria may also be causes of a form of peripheral paralysis. 
In speaking of facial palsy I have alluded to the variety known as the 
" Coup de vent." This sudden origin from exposure to damp and wind 
is, however, much more rare than that which follows intense cold. I have 
had several cases of this latter kind among draymen, sailors, and others 
who have been obliged to work for a protracted period in an exposed place. 
There is at first a numbness, and afterwards a complete loss of power, 
which may be bilateral. 

In peripheral paralysis there is a diminution of electro-muscular con- 
tractility after the first few days, and if there be complete section of the 
nerve this susceptibility to electric stimulation is lost, first to the faradic, 
and at the end of a week or two to galvanic stimulation. If a few fi- 
bres remain intact, it will be found that certain muscles are unaffected, 
and of course electrical irritation meets with a ready response. Changes 
of color in the paralyzed limbs are the rule, and there may be an ex- 
tensive blanching or patches of discoloration dependent upon the irregu- 
lar circulation. Analgesia and aniBsthesia generally exist in some degree, 
while changes of temperature are not so readily perceived as on the sound 
side. 

As the nerve is restored, electro-muscular contractility returns, and finally 
the patient is enabled to produce contraction at will. 

Arlong and Tripier^ have alluded to the rapid return of sensibility in 
distal parts after nerve section, and explain it by the theory that there are 
small communicating fibres betwetn the severed portions, but this view 
has not been generally received The expression of certain well-defined 
peripheral paralyses is anatomically the following : — 

UPPER EXTREMITY. 

Paralysis of the Circumflex Nerve: Loss of function of deltoid and teres 
minor muscles. The patient is consequently unable to put his hand to his 
head or raise it from his shoulder. The skin over the shoulder is auses- 
thetic. 

Paralysis of the Musculo-Spiral Nerve: Loss of function of supinators 
and extensors. The loss of power is quite decided and there is some ac- 
companying anaesthesia confined to the back of the forearm and a part of 
the hai.d. The extensor paralysis of the middle and index fingers is quite 
conspicuous. 

Paralysis of the Ulnar Nerve: Loss of function of many of the import- 
ant flexors, notably of the f. profundis and f. carpi ulnaris — shown in 
difficulty of flexing hand and little finger. Adduction is enfeebled. 
Sensation is blunted pretty much all over palmar surfiice; to a marked 
degree over thumb and over the two inner fingers and half of the third 
finger. 

Paralysis of the Median Nerve : The patient presents chiefly evidence 

^ Journal de TAnutomie et Pays , etc , March and April, 187G. 



TRAUMATIC PARALYSIS. 559 

of flexor paralysis, more profound than in last mentioned variety. The 
muscles of the ball of thumb are affected so that it is extended through 
antagonistic contraction of extensors. The palm of the hand and radial 
side of ring finger are anaesthetic. Through paralysis of the pronator 
radii teres he cannot pronate his hand. 

LOWER EXTREMITIES. 

Paralysis of the larger nerves does not commonly occur as a result of 
pressure or injury at a point in their course outside of the pelvis. 
Sciatica is occasionally attended by loss of motor power, and aggravated 
glandular disease may give rise to crural paralysis. Syphilitic infiltra- 
tion may prove to be the origin of such trouble, or aneurismal swellings 
may be attended by the evidence of neural pressure. Pain and surface 
anaesthesia are associated with such paralyses. Falls and blows upon 
the buttocks may give rise, in rare instances, to paralysis of the muscles 
of the thighs and buttocks, and Wilks speaks of the wasting of the glutei 
muscles as an evidence of loss of power and an accompaniment of certain 
neuralgic affections. 

Paralysis of the nerves of the leg interest us much more, and as a con- 
sequence, we are furnished with weakness in the movements of the leg 
and foot. Peripheral paralysis resembling, in some respects, so far as the 
loss of power is concerned, certain spinal paralyses of organic origin. 

Piiralyus of the Peroneal Nerve : Extensor paralysis of muscles sup- 
plied by its branches, viz. : External saphenous, musculo-cutaneous and 
anterior tibial. As a result, the muscles upon the anterior and outer part 
of the leg and toes are paralyzed with anaesthesia, chiefly of the integu- 
ment covering the anterior part of the leg, and the inner side of the great 
and second, and the whole of the third and fourth toes, and the inner side 
of the little toe. 

Parahj.ns of the Posterior Tibial Nerve : Loss of function of the pos- 
terior UiUscles of calf, and the flexors and abductors of toes. There is 
cutaneous anaesthesia of the plantar surface. The anaesthesia maybe 
confined to the outer side of the fourth and little toes. 

Diagnosis and Prognosis. — Progressive muscular atrophy and 
cerebral diseases are to be disposed of, and if we see the case alter the 
onset we may be deceived. In the former it must be remembered that 
there are fibrillary contractions, and that the atrophy precedes the 
paralysis. The electro-muscular contractility is also preserved for some 
time. 

In cerebral paralysis the electro-muscular contractility is preserved, and 
if anything exaggerated. Cerebral palsies do not involve such extensive 
sensory impairment. Spinal paralyses are usually bilateral, a fact which 
distinguishes them from peripheral troubles. 

Mitchell also alludes to the fact pointed out on a previous page, that in 
peripheral palsies there is none of the delay in transmission of impression 
which characterizes either spinal or cerebral trouble. 



560 DISEASES OF THE PERIPHERAL NERVES. 

WestphaP has in reviewing an admirable article by Vulpian,^ referred 
to the various interesting pathological changes which follow division 
of spinal nerves. His experiments were made to determine the muscle- 
changes which follow separation from the cord. His conclusions may- 
be thus summed up : — 

If a spinal nerve be cut through at any point between the spinal gang- 
lion and the periphery, the nerve-fibres of the central portion undergo 
atrophy en masse, without their individual character being altered ; but 
the peripheral part of the nerve-trunk undergoes what Vulpian calls 
" histopathic change," i. e., a breaking up or " splitting" of the medullary 
substance. 

Atrophy of muscles follows section of a motor nerve ; and, in addition 
to this, electric contractility is impaired. 

The absence of central symptoms of any kind, the loss of both motion 
and sensation in a limited area, absence of reflex contractions when the 
sensory fibres are irritated, and voluntary motion lost, are evidences of 
the peripheral nature of these paralyses. 

Treatment. — Traumatic paralysis, like the facial form, should be 
treated with an idea of removing the cause should it exist, and afterwards 
restoring the integrity of the nerve and muscles, and preventing muscu- 
lar atrophy. If the nerve-trunk be severed, of course all we can do is to 
await the union of the divided ends. If a tumor makes the destructive 
pressure, it should be removed if possible. It is hardly necessary to 
allude to the paralysis following dislocations, for of course the surgical 
proceeding, which is indicated at first, is the reduction of the luxated 
bones, and this should be done as early as possible. 

In the management of paralysis, which, Desplats^ says, may be due to 
pressure made by osseous enlargements, iodide of iron and other proper 
remedies, with cod-liver oil, are to be employed. If there be neuritis, it 
should be met with counter-irritation, emollient applications, or leeches. 

General supporting treatment may be necessary if there be a depraved 
condition of the system. 

The three valuable local forms of treatment are : 1. Electricity ; 2. 
Strychnia, internally or hypodermically ; 3. Massage. 

The first agent may be used as early as possible. If one current will 
not produce contractions, we may use the other ; and, if complete sever- 
ance of the nerve has taken place, it may be necessary to employ gal- 
vanism. Faradism is especially valuable should there be anaesthesia, and 
may be applied to the cutaneous surface. The galvanic current may also 
be used at the same time, so that one electrode shall be applied to the 
spine, and the other to the extremity. The individual muscles are to be 
subjected to daily galvanic stimulation. 

The production of pain is unnecessary, and I may repeat the clinical 
rule so tersely applied by H. C. Wood:* "Always select the current 

1 Centralblatt fiir Med. Wiss., July 13, 1872. ^ Comptes Kendu, 1872, No. 15. 

' D^8 Paralyses Peripheriques, Paris, 1876, p. 45, ''Phila. Med. Times, Feb. 20, 1875- 



TEAUMATIC PARALYSIS. 561 

which produces the most muscular contractions, with the least amount of 
pain." Pain and over-fatigue, which follow the use of a strong current, 
are very apt to thwart any probable success. The application should last 
not more than ten or fifteen minutes every day. 

An excellent method of treatment is to place the paralyzed limb in a 
vessel of warm salt water, and to introduce therein two metallic plates 
connected with a faradic machine. If there be neuritis, induced electricity 
does great harm and should not be used. 

I have repeatedly witnessed the beneficial results which followed the 
use of hypodermic injections of strychnia. An injection of s'o of a grain 
may be thrown under the skin over the paralyzed muscles. This may be 
repeated daily ; and I have sometimes seen its good eflfects when electricity 
was without avail. 

The use of " massage " should be employed in conjunction with the 
other treatment, and the muscles should be separately kneaded and 
rubbed for an half hour each day. This auxiliary treatment is of immense 
value when there is suspected rheumatic exudation. 

I have often employed apparatus by which the paralyzed limb could 
be subjected to warmth, and for this purpose have used a heated drain- 
pipe lined with cotton- wool, such as has been spoken of on another page. 
Into this the patient was directed to place his arm and allow it to remain 
for an hour or so each day. The paralyzed limb may be wrapped in cot- 
ton and oil silk, or India-rubber tissue. 

The union of divided ends has been resorted to by Tillaux,^ Nelaton, 
and others, and with a great deal of success. In Tillaux's case the median 
nerve was united by sutures, and within a day or two the patient was able 
to move his thumb, and there was some return of sensation. 

Mitchell'^ employs the following method: He carries a needle, threaded 
with one or two threads, through the loose tissue which is related to the 
nerve-sheath. The loops are drawn with care, so that the ends are 
approximated. Hot and cold douches and electricity are subsequently 
used. 

In some cases we may use Van Bibber's apparatus. 

Van Bibber presented the following case to the Maryland Medico- 
Chirurgical Society which illustrated the beneficial results of treatment of 
this kind : — 

" A youth, set. 16, about three years ago sustained a fracture of the 
right radius, which resulted in paralysis and atrophy of the extensor 
group of muscles. He first came under my observation about three 
months ago, when I found the following condition of the arm : radius 
curved; hand flexed, and the flexors acting inordinately; complete atro- 
phy of the extensor muscles, it being impossible for him to move his hand ; 
no response of the muscles to electricity; and the skm tightly bound over 
the radius. The treatment has consisted in rubbing and pinching the af- 



36 



^ Quoted by Weir Mitchell, Dis. and Inj. of Nerves, p. 238. 
2 Ibid., p. 243. 



562 DISEASES OF THE PERIPHERAL NERVES, 

fected muscles, the application of electricity, and the use of the artificial 
muscle, which is nothing more than an elastic tubing fixed to the back of 
the arm. The results of treatment have been very satisfactory ; the lost 
muscles have been restored, the skin has regained its former tone and 
elasticity, and the motion is fast returning." 

I may in conclusion present a case which was reported by Bernhardt, 
in which electricity was used. 

"L.,^ 43 years old ; dislocated his left humerus by falling on his left 
shoulder. He had pain in the shoulder, and found it impossible to use 
his arm, and that felt cold. The dislocation was found to be subcora- 
coidal, and after eight days it was reduced. The pain ceased, but the pa- 
ralysis continued. In the palm of the hand there was, after three weeks, 
considerable scaling of the epidermis. Pressure on the shoulder was not 
painful, but a strong grasp of the triceps and of the muscles of the fore- 
arm was unpleasant. Occasionally there was a sense of formication from 
the middle of the arm down the extensor side of the forearm to the end 
of the fingers The left arm could be raised in a straight line forward 
about half a foot, but could not be carried backward nor across the breast. 
The forearm could not be bent on the arm ; only the supinator longus 
was rendered tense. Extension was impossible ; supination was slight. 
The hand could be raised somewhat. Abduction and adduction of the 
hand, flexion and extension of the fingers, were impossible. The pack 
of a needle was felt to the upper border of the lower third of the arm on 
both sides equally. In the lower third of the left arm, in the elbow- 
joint, and the upper part of the forearm, the skin is more bcnsitive on the 
right than the left. In the rest of the forearm, in the hand and fingers, 
the sensation is a little less on the left than right, but nearly equal. The 
muscles of the arm and forearm, of the hand and finger, as well as the 
deltoid, showed only the slightest reaction to the induction current. 
Likewise the use of a very strong galvanic current either to nerve or 
muscle, by opening or clo-ing, failed to produce contraction. 

*' From the 5th of January, every other day, the patient was treated 
with a strong galvanic current, the anode and the cathode being placed 
on the paralyzed muscles. After four weeks he could raise the arm forty 
degrees, also some distance backward, so as to touch the right shoulder 
with the left hand. Also, he could bend the forearm on the arm, and had 
some motion in the hand and fingers. After eight weeks more, motion 
was nearly restored. 

DIPHTHERITIC PARALYSIS. 

Diphtheritic paralysis may either take place as a feature of the diph- 
theritic attack, or it may appear during convalescence, or even several 
weeks after recovery. The paralysis is generally bilateral, and does not 
last any great length of time if the throat is alone afiected, and rarely ex- 
ceeds ten or fifteen days in duration. Should the loss of power begin at 
the same time as the acute disease, the progress of the case is much more 
apt to be favorable, and the paralysis disappears in a shorter space of time 
than if it occurs at a period subsequent to the disease. 

^ Berliner Klinische Wochenschrift, No. 5, 1871. 



DIPHTHERITIC PARALYSIS. 563 

Lanne states that a marked and sudden increase of temperature during 
the diphtheritic attack or convalescence is indicative of paralysis. 

The paralysis may be simply motorial, or there may be a corresponding 
loss of sensation which is variable in extent. 

The muscles of the throat are usually involved, so that regurgitation of 
fluids takes place through the nose, or there may be certain phenomena 
which are so well marked in bulbar paralysis, in which the lesion is one 
of a destructive character. When the limbs are paralyzed, there may be, 
according to Brenner, movements of a choreic character which depend 
upon the irregularity of the paralysis, the antagonism of certain groups 
of muscles being abolished. The organs of special sense are not unusually 
involved. There may be paralysis of the muscles of accommodation,^ 
neuro -retinitis, and sometimes ptosis. Deafness is not rare, and in one 
of my own cases there had been tinnitus immediately preceding the 
deafness. 

The following case is of a very interesting nature, from the fact that 
it is reported by the patient himself, who is a medical man.^ 

" In October, 1875, being twenty six years of age and in good health 
after two months' constant exposure to diphtheria, I was inoculated from 
a child two years old, who, on examination, coughed portions of the 
membrane into my face. Six days after this exposure I was seized with 
a chill, followed the next day (October 28th) by the appearance of a diph- 
theritic deposit on one tonsil. The deposit was limited to the tonsils and 
back part of the pharynx, and in nine days disappeared. Exhaustion 
and great gastric irritability retarded convalescence. Four weeks passed 
before I was able to sit up. Two weeks after convalescence was declared, 
a sharp, lacerating pain in the left axilla was noticed, recurring two or 
three times at short intervals. In a few days, after seeing visitors or 
talking a little, severe and constant pain in the elbow-joints occurred, 
which soon extended to the muscles of the arm and chest. After resting, 
these pains diminished or disappeared, and in a week entirely ceased. 
On attempting to rise, my limbs seemed surprisingly weak, but at the 
expiration of the sixth week a short walk was possible. After a brief 
period of improvement my legs began to grow uncertain and weak, and 
by December 10th I could take but a few steps. At this time a partial 
loss of sensation came on, beginning in the feet and gradually progressing 
to the trunk, together with a feeling of coldness in the feet, which, how- 
ever, were not cold to the touch. This numbness increased faster than 
the loss of motion. Soon after its appearance in the lower extremities 
the ends of the fingers lost their sense of touch, the loss of power also 
extending in a week to the elbows, and at no time greatly affecting the 
arm. L33s of motion in the fingers and forearm accompanied it, and 
increased for some weeks. The mouth, tongue, and portions of the face 
lost their sensitiveness at the same time and to the same degree. In a 
few days my voice grew thick, and was soon like that caused by cleft 
palate. The s)ft palate and uvula hung loosely in the mouth, and on 
attempting to swallow fluids they were regurgitated through the nares. 

1 See cases reported by Hutchinson, Lancet, Jan. 7, 1871. 

2 Dr. A. F. Eeed, Bjstoa Medical and Sargical Journal, July 13, 1876. 



564 DISEASES OF THE PERIPHERAL NERVES. 

Dimness of vision for a short time prevented reading. In three weeks 
my voice, then at times unintelligible, grew suddenly better, and in four 
or five days was restored. The difficulty in swallowing also soon disap- 
peared. The loss of motion and sensation in both arms and legs in- 
creased. In walking I seemed to be on velvet ; there was a sensation of 
coldness in my feet, and at first the circulation was retarded. The general 
loss of power was progressive until February 1st. It was then impossi- 
ble for me to stand alone even when lifted up, to raise myself an inch 
from the chair by my arm, to bring my thumb and forefinger together, 
or to exercise my strength in any part. The toes hung lifeless, and no 
reflex action was produced on tickling the sole of the foot. The urine 
was voided with difficulty, and the power of erection was gone. The 
interosseous muscles were wholly paralyzed, though still reacting to the 
faradic current. The fingers were drawn up when the hand was at rest, 
but only by great eflPort could be straightened out again. The muscles 
of the arms were much weakened, but with those of the thigh retained 
more power than the rest. They were also the last to lose and the first to 
gain motion. All these muscles were more or less responsive to the faradic 
current, the gastrocnemius least of all. During the weeks previous and 
at this date my appetite was excellent, and my food well digested. From 
this time an improvement as general as the invasion was noticed. In one 
week I could lift my body in the chair an inch or two, and when standing 
felt more secure. In two weeks I could raise myself up from the chair 
mainly by my arms, and undressed without aid. At the end of three 
weeks I could walk about the room aided by a cane, and wrote legibly. 
The difficulty in voiding the urine and loss of power of erection had by 
this time gone. In four weeks I walked out for a short distance, and in 
two weeks more all paralysis had disappeared, leaving some neuralgic 
pains in the knees and feet, which lasted but a short time. On April 1st 
I walked several miles without great fatigue. Atmospheric changes made 
no change in my strength. Insomnia was the greatest annoyance sufiTered 
while confined to the house. Three or four hours' sleep was all that 
could be obtained. The loss of sleep did not, however, leave me unre- 
freshed. 

"Treatment: From January 12th faradism to the muscles every day 
until February 15th, afterwards three times a week for three weeks. 
Tincture of nux vomica and tincture of phosphoric ether were given for 
ten days. The stomach rejecting these, one-thirtieth of a grain of strych- 
nine was substituted, which was increased to one-fifteenth three times 
daily for six weeks. A pint of ale daily for two months. Friction and 
kneading of muscles every morning for one hour." 

Causes. — Morbid Anatomy and Pathology. — Dowse ^ quotes 
Balthazar Foster, who has stated that " he has never known paralysis to 
follow the non-febrile form of diphtheria." Dowse thinks that the vio- 
lence of diphtheria has little to do with the development of the paralysis, 
and says that he has seen cases following modified attacks. 

My own experience leads me to disagree with him. I have seen six 



1 See case reported by Dr. A. W. Foot, Dublin Quarterly Journal, Sept. 1872, p. 
176, of " Locomotor Ataxia subsequent to Diphtheria." This was evidently the 
ataxic form of Brenner. 



DIPHTHERITIC PARALYSIS. 565 

cases of diphtheritic paralysis, and these were among the most violent 
cases. 

Labadie Lagrave, Andral, and others have called attention to tlie blood- 
changes in this disease, viz., diminished fibrine and an increased number 
of white corpuscles. Saune has found that the red corpuscles are de- 
stroyed, and that there is a great increase in the amount of debris with 
albuminous urine. The paralysis takes place, however, in a later stage, 
but Dowse has shown that the albumen in the urine reappears with the 
paralysis, and that it again diminishes in quantity as recovery takes place ; 
hence we may infer that a connection exists between the blood condition 
and the paralysis. I am inclined to think that the paralysis of the palate 
and muscles of the pharynx are the results of pressure made by the diph- 
theritic mem. bran e. 

Diagnosis. — Diphtheritic paralysis need not be mistaken for any other 
affection, though occasionally, in its ataxic form, it is confounded with 
posterior spinal sclerosis. Its transitory nature should render such an 
error as this impossible. For the same reason it should not be confused 
with organic paralysis. 

Prognosis. — I have never heard of a fatal case, that is, a death which 
was a result of paralysis occurring during convalescence from diphtheria. 
When paralysis takes place before the violence of the disease has been 
spent, death may take place from the acute disease. The duration of the 
paralysis is from eight or ten days to many months. 

Treatment. — Nutritious food, massage, strychnia, and iron, quinine, 
and stimulants with faradization, are the indications. The plan pursued 
in Dr. Reed's case will serve as a model for others to go by. 



566 DISEASES OF THE PERIPHERAL NERVES. 



CHAPTER XIX. 

DISEASES OF THE PERIPHERAL NERVES (Concluded). 
LEAD POISONING. 

Synonyms. — Colica pictonum ; Plumbism. 

The toxic effects of lead, whether taken internally''or absorbed by the 
skin, are extremely varied and interesting. Disorders of motility and 
sensation are produced which, though rarely alarming, are m'ost distress- 
ing conditions. 

Symptoms. — Among the early symptoms of lead poisoning may be 
mentioned the abdominal pain which has received the name of colica 
pictonum, and which Romberg^ considers a species of neuralgia of the 
mesenteric plexuses. Tanquerel ^ has graphically sketched the appearance 
and development of this symptom. At first there is constipation which 
lasts for some weeks, and sometimes follows a slight diarrhoea, while after 
a short time a sense of epigastric oppression is experienced, with nausea 
and eructations, and gnawing twisting pains which occupy the umbilical 
region. These pains are much worse at night, and rarely shift their posi- 
tion. Pressure relieves them to some extent, as it does in simple colic. 

During the paroxysms there is great muscular rigidity, and the ab- 
dominal muscles seem to be rigid. The skin is cool, and perhaps bathed 
in sweat, and the pulse is full and bounding, and quite hard. The con- 
stipation continues, and the feces that are occasionally voided are scyba- 
lous and of a whitish-gray color. The urine is of high specific gravity, is 
quite light in color, and voided in considerable amounts. 

The complexion of the individual is sallow, and the skin rough ; and, 
if his lips be separated, the peculiar bluish line at that part of the gums 
which is in contact with the teeth will be seen. This line is a quite con- 
stant symptom ; it is perhaps one of the most valuable diagnostic marks. 
The remaining part of the gums is quite spongy and dark. 

There may be in conjunction with lead colic a very well-marked cuta- 
neous ansesthesia or hypersesthesia., but the latter is more common. The 
skin is exquisitely sensitive in parts, such as the scalp, the groin, the bend 
of the elbow, and other like regions. Pressure seems to relieve this ten- 
derness, but light irritation aggravates it markedly. 

A form of tremor which is apt to be confused with those of a sclerotic 
nature has been found as a rare symptom. Brockman observed it among 

1 Op. cit. vol. ii. p. 132. 

2 Traite des Maladies de Plomb. ou Saturnines, 1830. 



LEAD POISONING. 567 

workers in the lead mines of the Hartz Mountains. It may be local or 
general, and in the first form the hands are affected. The lips may be 
agitated, and the levator angali oris is often involved, so that the corner 
of the niouth is drawn up. In the other formthe head, trunk, and arms are 
all in a state of tremor, the head being bowed on the chest, and the legs 
unsteady. In this latter form there is usually a profound toxic condition. 

By far the most important symptom, and one which may or may not be 
preceded by lead colic, is the form of local paralysis known as " lead 
palsy" or " lead paresis." The onset of the malady is usually gradual, 
the patient being unable at first to extend the fingers. There is nearly 
always some numbness of the hand, and rarely tremor. It is not often 
that the paralysis becomes general, but the extensors of the forearms are, 
as a rule, involved. In this condition the hands hang helplessly, and an 
appearance' results which has been called ''drop wrist." There is gen- 
erally some paralysis of the flexors, but this is almost inappreciable. 
Other muscles, notably those of the shoulder, are affected if the lead 
saturation be profound, and, as a consequence, the patient maybe unable 
to raise his arm. I have never seen a case in which the lower extremities 
were involved. 

Electric sensibility and C9ntractility are much reduced, and there is 
marked anaesthesia in most of the cases. Faradism rarely provokes mus- 
cular contractions, and in old cases even the galvanic current fails to call 
forth the slightest response. 

Atrophy is a result of the paralysis, and the interosseous spaces of the 
forearm are sometimes very plainly marked, the loss of substance being 
quite decided. 

The colic generally subsides with the appearance of the paralysis, and 
according to Komberg ^ the two conditions rarely co-exist. In the cases 
recorded by various observers the muscles of both extremities of one kind 
were affected in the great majority of instances, and from my own expe- 
rience I consider unilateral lead paralysis to be an anomalous condition, 
but impaired function not equal. 

Occasionally a cerebral condition results from lead poisoning, and gene- 
rally follows the colic. This is characterized by vertigo and headache, 
general malaise, and tremor of the hands which is aggravated by volun- 
tary action. A more serious state is sometimes produced, however, which 
is symptomatized by delirium, convulsions, and stupor. 

The duration of lead paralysis, or the other conditions I have noticed, 
is of course governed by the existence of the cause and the exposure of the 
patient. Most of the toxic lead states disappear, however, in a very short 
time, provided the patient protects himself by leaving his injurious occu- 
pation, and the proper remedies be administered. 

The folio wiag may be cited as a well-marked case of lead poisoning : — 

Jas. McK., set. 55, N. Y. City, painter. Has followed his trade 35 
years, engaged mostly on "inside work," "flatting." Never had any 

1 Op. cit., vol. ii. p. 136. 



568 DISEASES OF THE PERIPHERAL NERVES. 

trouble till two years ago, when he noticed pains in his limbs, back, and 
suboccipital region ; not much colic, but some nausea ; loss of appetite ; 
not constipated. While actually engaged in work he became dizzy, and 
" a blur came across his eyes." Last acute attack was obliged to leave 
work suddenly on account of severe backache. He then noticed a loss of 
power in right hand.' He consulted me in July, 1877, presenting well- 
marked " wrist drop," so that he was unable to extend his hand. He com- 
plained of formication of soles of feet, insomnia, and pains in shoulders, 
knee-joints, and about heart. Well-marked blue line and very dirty gums. 
The necks of the teeth are carious and black, and he has lost several of 
them during the past few years. 

Loss of sensation of cutaneous surface. 

Hand — Atrophy of adductor of thumb, so that quite a hollow exists. 

Forearm. — Complete loss of electro-muscular contractility iu common 
extensor of right forearm ; slight power under electrical stimulus of ex- 
tensor of thumb and little finger. Flexors slightly impaired, but con- 
tractility scarcely lost. 

Arm. — Muscles all contract well. Patient cannot take off his coat or 
underclothing, or cannot button his clothes. 

Treatment — Electricity and potass, iodid. with strychnine. 

Causes. — The majority of cases of lead poisoning arise from the inspi- 
ration of finely divided particles of lead, and not from the manipulation of 
pieces of the metal ; consequently, painters, smelters, white-lead makers, 
and miners are more often victims than any other classes of individuals. 
There seems to be an idea that printers are especially subject to lead dis- 
eases ; and at the request of the Board of Health of the city of ^ew York 
I made an extensive examination of the printing- offices for the purpose 
of testing the question. I interviewed nearly 1500 men, women, and 
children, and found not a single case of paralysis. Among the grinders 
of type (those who smooth the sides and ends of the type against large 
rough stones),! found that the persistent use of the muscles of the thumb 
and forefinger, in one case, resulted in a condition resembling progressive 
muscular atrophy. In the lead pipe and shot manufactories my expe- 
rience was the same. 

The painters, however, seem to be most frequently poisoned. An ope- 
ration known as " flatting," in which the painter closes all the doors 
and windows of a room, and applies thin paint, is attended with great 
danger. The turpentine evaporates rapidly, and carries with it minute 
particles of lead which the workman must inhale. 

Dr. Richardson,^ in a thesis which embodies a large amount of valuable 
research, thus describes the manner of preparing white lead, and the dan- 
ger which attends its manufacture. 

" The metal first comes in contact with the skin of the men in being 
•carried by hand from the cars to the melting-room. Here many tons are 
melted at once and cast into thin, circular, perforated plates called buck- 

1 Can only force dynamometer index to 4 with right hand; left, 15. 

2 Graduation Thesis, Harvard Medical School — Boston Med. and Surg. Journ., 
Oct. 4, 1877. 



LEAD POISONING. 569 

les, of such shape as to expose as much surface as possible for the weight. 
The temperature is very high. Bathed in perspiration the men stand for 
hours inhaling the minute particles of the oxide of lead which escape 
from the cooling buckles and fill the air. Their thirst in this part of the 
process is insatiable, and enormous quantities of ice-water are swallowed, 
whereby the dust, which adheres to the tongue and lips, is washed directly 
into the stomach. 

Having been carried to a neighboring shed, the buckles are placed 
over pyroligneous acid in earthen pots of about four quarts capacity. 
Many thousands of these pots are packed together in the refuse of sta- 
bles or the exhausted bark from tanneries, and are exposed to the mode- 
rate heat which is spontaneously generated about them. The wood vine- 
gar is volatilized and rises through the buckles, changing by sime obscure 
chemical reaction the blue metallic lead into the white carbonate. After 
an exposure of this sort, lasting from six weeks to three months, the pots 
are unpacked and the whitened lead removed. Here for hours men 
breathe the vapors rising from the heated bark, loaded with poisonous 
particles of the now dusty metal. In English mills this part of the pro- 
cess is done by women, with most disastrous effects upon the health. To 
separate the blue from the white lead the buckles are placed in a revolv- 
ing cylinder of wire-cloth, through which the carbonate, more or less pul- 
verized, falls. The blue portion remains in the cylinder and is melted 
again. To be in this room without protection is suicidal, for the air is 
filled with visible clouds of dust The utmost care must be taken. The 
mouth and nostrils are covered by a moist sponge to catch the floating 
particles. The skin and clothes quickly become white with lead. The 
semi-powdered metal, having been shovelled into barrels and rolled into 
another division of the works, is mixed with water and finely ground. 
When it fills the water as a milky precipitate, the whole is drawn off and 
dried on long tables at a temperature of 140^ F. Formerly the grinding 
was done without water, and the lead sickness was much more common 
than now. The drying-room is the most poisonous one in modern mills. 
It combines the effects of the dust which fills the air with those of a 
heated atmosphere. Here, as in the melting-room, the skin is kept in 
the best state for absorption. A terrible thirst makes the men swallow 
large quantities of cold water with the lead which accumulates on their 
lips and tongues, while at every breath fine dust is drawn into the lungs. 

The general appearance of the men is not good. The faces are sallow 
and more or less worn. The sclerotic coat is yellowish. Their motions 
are far from energetic, and in some cases eccentric and unsteady. One 
would say immediately, I think, that the general appearance is much be- 
low that of the average workman. 

1. The first man examined has worked in all parts of the mill for thir- 
teen years. His only trouble is rheumatism. The gums show a distinct 
blue line along the border. 

2. After seven years in the corroding rooms has no symptoms except- 
ing the blue line. 



570 DISEASES OP THE PERIPHERAL NERVES. 

3. After grinding lead with oil has only the blue line. 

4. After working in all parts of the mill for six months has had violent 
colic and great constipation. Blue line marked. 

5. Keports only blue line after four years' work. 

6. The machinist, after repairing in the drying-room a few hours a day 
for ten days, was affected with colic and constipation. Has great habitual 
constipation. Blue line very marked. 

7. After seven years only blue line. 

8. After twelve years has only blue line and fungous bleeding gums, 
with occasional colic and obstinate constipation. 

•9. After six years in corroding-room has only blue line. 

10. Has worked in all parts of the mill for fifteen years without showing 
a trace of blue line or any other symptoms whatever. Very neat. 

11. After three years only blue line. 

12. After four years, nothing. 

13. Blue line, rheumatic pains, and fainting fits. This was a remark- 
ably neat man. 

14. After four years no trace of poisoning. 

15. After four years entirely used up. Had to leave all work. 

16. After one year's work completely crippled, having paralysis of the 
extensors, aphonia, and general debility. 

17. The carpenter, after repairing ten days in the drying-room, had se- 
vere colic, obstinate constipation, and persistent blue line. 

18-75. Of the rest of the seventy-five men whom I examined all had a 
distinct blue line about the gums, and, with one or two exceptions, habit- 
ual constipation. There was nothing further than this to suggest the 
presence of lead. 

In addition to the above cases, three of the former employes had suf- 
fered with difficulty in speaking, three with amaurosis, several with cere- 
bral troubles, and many with paralysis. The superintendent has ob- 
served that the most frequent complaint has been of swollen joints and 
aching bones. In the numerous cases of paralysis which he has seen 
during many years' service at these works, he has noticed that the wrists 
have become much swollen before paralysis of the extensors. A curious 
tradition exists among them that they cannot drink alcoholic liquors and 
keep up with their work, like laboring men in other manufactories. Sev- 
eral cases were told me of men who quickly succumbed to the influence of 
the lead after beginning the use of strong stimulants." 

Lead is often taken into the stomach without the knowledge of the 
individual, and lead pipes are a prolific source of the contamination of 
water. I have seen three cases in the same family caused by tea which 
had been made from a specimen containing particles of sheet lead which 
had lined the box. The last two or three pounds were impregnated 
with these impurities, which had settled to the bottom of the chest. It 
was the custom to make tea and from time to time to add fresh leaves and 
pour on hot water, so that there was constantly a quantity of lead sub- 



LEAD POISONING. 571 

jected to the action of the fluid. Upon analysis, quite an amount of lead 
was found. 

Cases arising from the use of cosmetics and hair-dyes are two common 
to need anything more than bare mention. 

Morbid Anatomy and Pathology.— Andral and Tanquerel^ 
were unable to discover any pathognomonic condition of the intestines in 
lead colic; but the latter authority found lead deposits in the intestines, 
muscles, and nervous substances. In a case of lead paralysis reported by 
Gombault,^ there was found to be no change in the cord, and the only 
morbid appearances anywhere else were in the nerves, the medullary 
substance having undergone a granular alteration. jSTo other appear- 
ances which might clear up the pathology of the affection have been 
seen. 

Remak^ is of the opinion that lead palsy is a central disease, and he 
presents several cases to show its likeness to infantile paralysis. The 
same electrical reaction of the muscles in these two affections, and the 
fact that groups of muscles are affected which act together, not neces- 
sarily being those supplied by the same nerve, leads him to think that the 
paralysis is of central origin. The blue line of the gums, which indicates 
plumbic saturation, was first described by Burtoa in 1840. By 
Tanquerel it is supposed to be produced by the decomposition of food 
about the teeth, the sulphuretted hydrogen uniting with the lead. It 
occurs in people who brush their teeth as well, however, as in those of 
careless and untidy habits. Dr. Richardson* tried the following experi- 
ment : — 

" A strong, healthy cat was fed for a week upon milk, to which had 
been added a small portion of a solution of plumbic acetate. At the end 
of a week the animal was killed, after having shown symptoms of severe 
constitutional disturbance. The lower jaw was excised, and the gams 
found perfectly clean. The upper jaw was also clean. The lower jaw 
was placed in water, through which a stream of sulphuretted hydrogen 
was passed for several hours. At the end of that time a perfectly distinct 
and unmistakable blue line was found throughout the juncture of the gum 
with the teeth. The stomach and intestines of the animal showed nothing 
remarkable. The presence of the blue line seems, therefore, to depend 
on a certain amount of putrefaction about the teeth." 

The elimination of lead is usually rapid when the proper remedies are 
administered to convert it into a form for excretion. If nature is left to 
herself, the proce?s is more slow. Potain considers that it is eliminated 
only very slowly by the swcat-glands, and not by the kidneys or salivary 
glands, but I am disposed to consider that elimination does take place by 
the kidneys. 

1 Tanquerel, p. 326. 

^ Archives Generales, 1873. 

^ Archiv fiir Psychiatrie and Nervenkrankheiten, vi. p. 1. 

4 Op. cit. 



572 DISEASES OF THE PEEIPHEKAL NEKVES. 

Diagnosis. — In nearly all cases of lead poisoning, it is usually pos- 
sible to detect the cachexia, which is so well expressed by the different 
signs I have enumerated. If our suspicions are not verified by appear- 
ances in an acute case, we may test the patient's urine. A few drops of 
a solution of pota«sic sulphide will usually precipitate any lead that may 
be present in the form of a black sulphide. 

The paralysis may be sometimes confounded with other forms, but 
when it is remembered that the extensors are prominently affected, and 
that there are lead symptoms at some time or other, it is not possible to 
be misaken. 

Dr. Wharton Sinkler,^ in an admirable paper, calls attention to the 
resemblance between *' wrist drop " due to lead poisoning, and paralysis 
of the extensors from injury of the musculo-spiral nerve. He has found 
paralysis of the flexors of the forearm after injury of the nerve, and he 
is inclined to think that in the beginning there is never paralysis of the 
flexors in lead palsy. In lead paralysis the supinators escape. 

Prognosis. — With the disappearance of the cause, we may expect in 
most cases a rapid subsidence of symptoms. It is true the paralysis often 
lasts for some time, but even this ultimately disappears. Deaths by lead 
poisoning are rare^ and I suppose when they occur are due to an affection 
•of the brain, to which I have alluded. The mortality from lead poison- 
ing in New York City from 1852 to 1873 was 288. 48 died in 1852 ; and, 
strange to say, but four in 1872.'^ 

Treatment. — If we have correctly diagnosed the condition, our ob- 
jects must be : 1. To relieve pain ; 2. To favor elimination of the lead ; 
3. To guard our patient against being continually affected ; 4. To restore 
the paralyzed limbs. 

1. No better remedy is possessed than iodide of potassium, which forms 
an iodide of lead which is an innocuous salt. This drug must be given 
in moderate doses,^ and its elimination hastened by mild purgatives. It 
will be found that, if the patient is obliged to continue at his work, small 
doses taken daily, or acidulated drinks, will, in some measure, prevent 
the absorption of lead. If there be colic, the hypodermic use of mor- 
phine will give great relief. 

It has been found that those workmen who drink a great deal of milk 
seem to escape the danger of lead-poisoning. In France the workmen in 
the lead-works are obliged to drink milk, and it is found to be an excel- 
lent prophylactic. Richardson's case (loe. cit.) did not suffer so long as 
he kept his cows ; but when he parted with these animals, and stopped 
drinking milk, the most decided symptoms of plumbism manifested them- 
selves. 

As to the employment of electricity, it is well to use the faradic cur- 
rent if possible ; but in some cases this produces no contractions. In 

^ Am. Psych. Journal, Nov. 1875, p. 31. 

2 Report of the Board of Health, 1872. 

^ Very large doses seem to increase the symptoms. 



LEAD POISONING. 573 

such an event we may begin with the slowly intermitted galvanic current ; 
and, after a while, it will be found, as in some other paralyses, that the 
faradic will cause muscular response, particularly if the arm be so sup- 
ported that the mnscles shall be relaxed. Dr. H. C. Wood,^ of Phila- 
delphia, has noticed the fact that voluntary power may return to a great 
degree without a corresponding return of electric contractility. 

I have before alluded to an instrument devised by Dr. J. Van Bibber,^ 
and it is well to apply this so that the muscles may be entirely supported. 

In conclusion, I may present the records of a representative case of 
lead palsy. The patient was under the care of Dr. Cross, through whose 
kindness I had the opportunity of seeing him : — 

M. C.,^ aged 32 years, single, born in Ireland, a painter by occupation. 
He has been moderately temperate in his habits, and has always enjoyed 
good health until 1863. when he was suddenly seized with a severe attack 
of colic, which was preceded by great constipation of the b(»we]s and loss 
of appetite. There soon succeeded nausea and vomiting of bile, accom- 

^ Phila. Med. Times, Feb. 20, 1875. 

^ " After many attempts to secure this advantage by means of strips of plaster, it 
was determined to try the India-rubber muscle as used by Dr. Lewis A. Say re in 
orthopedic surgery. The great ditEculty in the use of such an appliance was to 
effect its application without causing injurious pressure upon the circulation of the 
arm and hand. I am not aware that these elastic tubes have been used before to cor- 
rect this deformity, or attached by a method so simple and so free from pressure as 
that which I shall now describe. Two bands of inelastic webbing, pierced by eyelets 
at certain points, and each having a convenient buckle, serve as points of attach- 
ment. The one for the hand, about three quarters of an inch wide, so made, that 
the free end placed upon the palm pointing toward the thenar eminence, and the 
eyelet-hole resting on the ball of little finger, the band folded once around that finger 
and passed over dorsum of the hand, the buckle would come in a convenient place 
upon the palmar surface. The band for the arm about one inch in width, so arranged 
that the eyelet being placed upon a line a little above the external condyle, the buckle 
would rest upon the internal surface of the arm. 

As seen by the illustration, two transverse strips of plaster are adjusted to the 
arm so as to form an angle just below the eyelet, and thus relieve the band, Avhich 
should be buckled loosely, from all injurious traction. The fold around the little 
finger, and the muscle resting upon the webbing on the dorsum of the hand, enable 
us to buckle the band loose enough to insure perfect abduction of all the fingers. 
Finally, a piece of India-rubber tubing of correct length and medium elasticity, with 
one of Dr. Sayre's metallic hooks attached at each end, constitutes the entire appa- 
ratus. 

Looking upon this artificial muscle as performing to some extent the duty of those 
paralyzed, I can probably best describe its application by saying, in anatoudcal 
language, that it arises from a point a little above the external condyle, and passing 
downward on the extensor surface of forearm, under the cuff, which we might call 
the annular ligament, forward over dorsal aspect of the hand, passing between the 
index and second fingers, which serve as a trochlea or pulley, then transversely 
across the palmar surface of the hand, and is inserted at a point about the articula- 
tion of the fifth metacarpal bone with its first phalange." — N. Y. Medical Journal, 
May, 1874. 

^ Reported in the Psychological Journal, Jan. 1871, by Dr. Cross. 



574 DISEASES OF THE PERIPHERAL NERVES. 

panied by an acute lancinating pain in the epigastric region, wliicli was 
so severe that the patient was obliged to lie flat on the floor and press his 
abdomen strongly against that surface, in order to obtain temporary relief. 
These symptoms continued off and on for a period of about two weeks, 
gradually diminishiug in severity, however, especially after an evacuation 
from the rectum, which was only obtained with the greatest difficulty. 
His right leg at this time became oedematous. In the course of two months 
he resumed his usual avocation, that of a painter, but was not aware at 
this time that his sickness had been caused by the action of lead. During 
the year 1867 his bowels again became very costive; and his stools, which 
c )nsisted of only a few lumps of dry, hardened feces, were attended with 
much straining. 

Soon there followed a second attack much more severe than the first, 
which was characterized by nearly similar symptoms, only there was 
superadded great tenderness over the kidneys, which were ^o sensitive 
that the least pressure caused him the most intense agony. The urine 
was very scanty and high-colored, and there was a well-marked blue 
discoloration of the gums. In a few months, having somewhat recovered, 
he went to work again at his former occupation, which he pursued unin- 
terruptedly until the 25th of December, 1869, when, after having passed 
a very uncomfortable day, his former symptoms returned with increased 
violence, while the paroxysms of thie colic came on at much shorter inter- 
vals than they had done in the preceding seizures; in fact, instead of 
intermissions as formerly, there were only remissions of the intestinal 
spasm. For the first time he had pains in the feet and the inside of the 
thighs. The urine was more scanty and higher colored, and the bowels 
more constipated than before. 

In three weeks he again began to work, and had no more trouble, 
except constipation of the bowels and weakness in both his upper and 
lower extremities, until July, 1870, when he lost his appetite, and felt 
very weary and exhausted after any small amount of exertion. He was 
very restless and could not sleep at nights, and this inability to sleep was 
a sequela of all the .other seizures. Now came great tremor of the right 
hand and arm, which was soon followed by tremor in the left. 

In August, 1870, he had his fourth and last attack, which was the most 
severe of all, and lasted about two weeks. This time he vomited blood, 
had acute pains in the soles of his feet, and cramps in the right hand. 
On recovering from the effects of the colic he found that he was unable 
to use his arm or hand at all, and that he had lost power in his legs also. 

Soon after this he was admitted to the Charity Hospital, where he 
remained for a fortnight, and during his residence in that institution he 
became delirious, and continued so for about eighteen hours. He came 
to the out-door department of the New York State Hospital for Diseases 
of the Nervous System, September 12, 1870, when his condition was as 
follows: There was the characteristic drooping of both wrists, which was 
very extreme in degree. The paralysis of the supinator and extensor 
muscles of both upper extremities was exceedingly well marked; the 
flexors were also involved, only to a much more limited extent. The 
paralysis was more considerable in the right forearm and hand than in 
the left. There was much atrophy of all the muscles of these parts, and 
this was very conspicuous in the abductors and adductors of the thumbs. 
The patient was so very weak in his lower extremities that he was unable 
to arise from the sitting posture without assistance, and as he walked he 



FUNCTIONAL SPASM. 575 

tottered at every step. Yet he did DOt drag the toe of either foot, nor 
swing his legs, as do those suffering from hemiplegia. The blue line was 
very plainly seen around the edge of the gums of the upper and lower 
jaws. On testing the amount of muscular power in the right hand by 
means of the dynamometer, he was able to turn the indicator only 10 
degrees, while with the left he could accomplish somewhat more. The 
tactile sensibility and the sensibility to the electric current and to pain 
w^ere very greatly diminished. The temperature was also diminished ; 
muscular contractility was so much impaired that a powerful induced 
current had not the slightest effect in causing contractions, and, even 
when the primary galvanic current (sixty cells and very strong) was used, 
the muscles responded very feebly, if we except, perhaps, the flexors, so 
almost completely had their irritability been destroyed. The bowels were 
regular, the urine was normal, and, although no chemical analysis f>r 
lead was made, undoubtedly it would have been found. "The appear- 
ance of the patient was anaemic, cachectic, and depressed; the breath was 
very offensive; the retinae were anaemic ; the lungs were healthy, and so 
was the heart, excepting an inorganic murmur at its base." 

The treatment in this case has consisted of the internal administration 
of the iodide of potassium, commencing with ten-grain doses three times 
a day, and the daily application of the primary galvanic current to the 
paralyzed muscles, with a hypodermic injection of the thirty-second of a 
grain of the sulphate of strychnia every day. 

September 17. The iodide was increased to fifteen grains three times 
a day. 

2Uh. Slight fibrillary contractions in the right arm were produced to- 
day for the first time by means of the faradic current. 

October 1. The iodide of potassium was increased to twenty grains three 
times a day. 

bth. The induced current had just commenced to cause slight contrac- 
tions in the left forearm. 

November 15. Faradization of the left forearm produced good contrac- 
tions in the extensor carpi radialis and ulnaris muscles. The blue line 
having disappeared, the iodide of potassium was discontinued, and a tonic 
substituted. 

23o?. The muscles of both arms respond feebly to the induced current, 
yet by means of it the hands can now be extended nearly on a level w^ith 
the forearms. The right has improved the most. Sensibility to touch 
and to electricity has much improved. His bowels are regular, he sleeps 
well, and his appetite is good. The power in both hands is much in- 
creased, and he is able to work every day. 

January 1, 1871. The patient has almost entirely recovered. 

FUNCTIONAL SPASM. 

Under this head I propose to include the various forms of hyperkinesis 
which depend upon irritability of the nervous centres, and which have 
been specially considered, as Tetany, spasm with voluntary movements, 
Reflex Spasm, Torticollis, Professional Cramp, etc. 

These are generally due to some peripheral cause, or may result from 
overtraining of the automatic sense, or iu certain conditions arise in a 
manner which is at present not clearly understood. 



576 DISEASES OF THE PERIPHERAL NERVES. 

I. TETANY. 

A light form of attack arising generally from diarrhoea, cold and con- 
stipation, and sometimes making its appearance during lactation. There 
is usually some formication of the palms or soles, and an awkwardness in 
the movements of the hands and feet, which is afterwards followed by a 
firm tonic contraction of the muscles of either of these parts. The flexors 
are usually contracted, so that the hand is curved, or all the fingers closed. 
A more decided contraction may flex the forearm on the arm. The foot 
may be also affected, a condition of talipes resulting, or the back part of 
the leg may be brought in apposition to the thigh. In marked forms the 
upper and lower extremities are affected together, though there is no rule 
governing this, and the spasm may be bilateral or unilateral. The attack 
rarely lasts beyond an hour or two, and in the majority of instances relax- 
ation may take place in from five to ten minutes. The spasms may come 
on from time to time, being separated by greater or less intervals. They 
are entirely uncontrolled by the will, and the patient cannot open his fin- 
gers when they are thus contracted. In more severe forms the muscles of 
the trunk or face become involved. Contraction of the ocular muscles, 
laryngeal spasm, trismus, or vesical spasm are examples of more violent 
action. The spasms seem to be produced when pressure is made upon a 
nerve-trunk or muscular belly, and there is loss of tactile sensibility 
associated with neuralgic pain in the main nerve trunk of the convulsed 
limb. 

Tetany differs from true tetanus from the fact that the spasms affect all 
the limbs, that they are intermittent in character, and that there are in- 
tervals of relaxation. Petit-mal sometimes resembles this condition, but 
there is always some loss of consciousness. 

II. FUNCTIONAL SPASM WITH VOLUNTARY MOVEMENTS. 

Mitchell ^ reports some cases of functional spasm, which somewhat re- 
sembles the so-called tetany. The spasm appeared during the exercise of 
a voluntary act ; they occur with the act of laughing, chewing, and talk- 
ing, and evidently depend upon functional derangement of muscles inner- 
vated by the first cervical and spinal accessory nerves. In one case the 
head was drawn back, and the spine bowed so that the patient was jerked 
into a squatting posture, the gastrocnemius being finally afifected. 

In other cases the spasms occurred when the individual began to walk. 
In still other cases there was a rhythmical motion when the patient 
attempted any simple voluntary action. These Weir Mitchell called 
" pendulum spasms," the number of twitches averaging 160 per minute, 
and recurring with great regularity. 

Bamberger^ reports a case which resembled spasm of another kind, 
Whenever the child was held in the standing posture his legs were drawn 

^ Am. Journ. Med. Sciences, Oct. 1876. 

^ Quoted by Handfield Jones, Functional Nervous Disorders. 



REFLEX SPASM. 577 

up, and agitated by choreoid spasms, the spine and neck being twisted 
and contracted at the same time ; but when he was placed upon his back 
these movements ceased. 

III. REFLEX SPASM. 

Under this head may be classed a long list of local convulsive move- 
ments dependent upon a variety of causes. Sometimes there are worms 
in the intestinal canal, and at others a condition of irritability of the geni- 
tals ; while peripheral irritations of many kinds enter into the etiology of 
the spasm. 

I may illustrate the occurrence of one form of spasm by the following 
case : 

I. A boy, 7 years old, seen at the request of Dr. Sayre, was well 
nourished, with rosy cheeks and well-rounded muscles of the upper ex- 
tremities. His morbid condition had existed from birth, and he possessed 
a congenital phimosis, the prepuce being firmly fastened over the glans, 
and the preputial orifice was very sma.ll and surrounded by a rigid ring 
of toughened skin. On entering the room I was struck by the extra- 
ordinary restlessness and activity of the child. He was lying on the 

Fig. 71. 




Reflex Spasm from Genital Irritation. 

bed, and his lower limbs were drawn up and agitated by irregular spasms. 
The arms were also convulsed, and their movements were distinctly 
choreic. When held upright the child was unable to stand, not from any 
paresis, but from the apparent loss of co-ordinating power, the legs be- 
coming rigid, and the toes of both feet adducted, more particularly the 
left. The child was unable to speak, but attracted the attention of those 
around him by queer sounds. His face was distorted, just as we often 
see it in old choreic patients, but there was no evidence of imbecility. I 
did not infer that there was any mental trouble, except a preponderance 
of emotional disturbance, the boy being very fearful that he was to be 
hurt. Upon interrogating I found that he was quiet during sleep, that 
his appetite was good, and that there was no irregularity or disturbance 
of the functions of the bowels or bladder. The penis was not so sensi- 
tive as I had expected to find it from Dr. Sayre's description of previous 
cases. Titillation did not produce immediate erection, nor any increase 
of the spasmodic movements. On taking him upon my lap the thighs 
and legs were immediately drawn up ; there was no evident pain pro- 
duced by pressure on the spine. 
37 



578 DISEASES OF THE PERIPHERAL NERVES. 

A form of reflex spasm of the eyelids was reported by Von Graefe/ 
whicli rendered tlie patient helpless, for he was unable to go about alone. 
There was no pain produced on pressure in the course of the fifth nerve ; 
but when pressure was made on the glosso-palatine arch on the left lower 
jaw, the spasm ceased at once, and the patient could open his eyes. A 
putrid ulcer was found at this locality, which acted as a centre of irrita- 
tion upon the gustatory nerve. 

IV. FACIAL SPASM WITHOUT PAIN. 

A form of facial spasm not connected with voluntary motorial move- 
ment is occasionally met with, the orbicularis palpebrarum or buccinator 
being affected alone, or all the muscles of the face supplied by the portio 
dura being convulsed. The trouble differs from epileptiform tic for the 
reason that it is unaccompanied by pain. I have been so fortunate as to 
see two of these cases. One was that of a gentleman aged 56, who suf- 
fered an- almost constant spasm of the orbicularis of the eye, which was 
always increased when he was fatigued. The eye would become red, and 
there was usually a discharge of tears, which were unable to find their 
way into the lachrymal duct, and consequently ran on the cheek. Cases 
of unilateral painless spasm have been reported. 

V. TORTICOLLIS. 

The sterno-cleido mastoid muscle may be the seat of a spasmodic con- 
traction. This condition may be preceded by peripheral trouble, such as 
painful dentition, which was the cause in one of Komberg'a cases, or by 
such general disease as rheumatism. One case, which was seen by Dr. 
White and myself, was preceded by chorea, and another, that I saw at the 
New York State Hospital for Diseases of the Nervous System, was due to 
general anaemia. In both these cases, as well as in others I have ob- 
served the head was bent forward and the chin pulled downward. In 
one case, that of the elderly woman at the Hospital, the spasms were in- 
termittent. Radcliffe reports a case which somewhat resembles this. The 
muscles of the neck were tender and the seat of soreness, and the move- 
ments were attended by pain. The spasms are usually increased by emo- 
tional eS:citement, but subside during sleep. The notes of my case are the 
following : — 

M. A. A., aged 56, U. S. Came to the hospital Oct. 29, 1872. Her 
present trouble began five years ago in a very gradual manner. There 
are now marked clonic spasms of the muscles of the anterior part of the 
left side of the neck. With their intermitting contraction, there is some 
pain at the lower insertion of the sterno-cleido-mastoideus muscle ; the 
trapezius is also the seat of spasmodic contraction. There is headache, 
and pain at the upper part of the cord. Patient's expression anxious and 
excited. Galvanism to muscles and spine, and zinci phosphidi gr. i t. i. 
d. Patient complains of dizziness and constipation. 

1 Schmidt's Jahresbericht, vol. 127, p. 30 ; reported by H. Jones, p. 390. 



TORTICOLLIS. 579 

The muscles concerned in this form of disease are the sterno-cleido- 
mastoideus, complexus, trapezius, and levator anguli scapulae. 

Pathology. — Weir Mitchell has divided the conditions under which 
spasms of this kind may occur into three groups : — 

1. " Those in which the functional activity of a muscle or set of muscles 
gives rise at times to an exaggeration of the motion involved naturally, 
and sometimes also to a more or less spasmodic activity in remoter 
groups. 

2. " Those in which the functional action of one group results only in 
sudden and possibly in prolonged acts, tonic or clonic, in remote groups 
of muscles not implicated in the original movement. 

3. '' Those in which standing or walking occasions general and disor- 
derly motions affecting the limbs, trunk, face, and giving rise to a general 
and uncontrollable spasm without loss of consciousness." 

The central condition is one of great reflex irritability ; certain forms 
of repeated irritation producing an activity of the motor centre which re- 
sults in an abnormal increase in reflex susceptibility. 

Treatment. — Agents which lower the excitability of voluntary mus- 
cular action are to be adopted. Among these hyoscyamia, gelseminum, 
musk, ether and assafcetida are efficient when used cautiously. Rest, and 
removal of the peripheral irritation, should the spasm be of reflex origin, 
and the ether spray to the spine, are to be resorted to ; and at the same 
time various measures which improve the individual's general condition 
are in order. If all of these drugs I have mentioned be powerless to 
subdue the excitable condition of the muscles, I prefer profound bro- 
minization, which sometimes controls the movements. Myotomy in tor- 
ticollis has not proved itself to be a successful operation, and so I do not 
recommend it. In other conditions, such as adherent prepuce, an opera- 
tion is the only method that promises a cure. 

The use of electricity in spasmodic affections is to be resorted to as 
promptly and thoroughly as possible. In torticollis it has hitherto 
been only moderately beneficial. 

The lack of uniform success in the cases reported and a realization of 
the fact that electricity is of such great use in so many other spasmodic 
affections leads me to believe that many more patients might be relieved 
if the treatment were directed with a view to meet the pathological indi- 
cations, which after all seem plain enough. In the early stages, it appears 
that the anterior muscles of the neck are not primarily affected, but 
rather the trapezius, and at such a stage the electrization of the sternp- 
mastoideus seems unwise. In other cases the approximative galvanization 
of the spinal accessory is indicated, while in the confirmed cases, which 
by the way we see the most of, I am about to speak of a treatment which 
I am not aware has been described heretofore. I find no allusion to the 
simultaneous employment of the two currents for the production of their 
physiological effects. 

In the early part of 1879 my attention was first called to their use by 
a patient who had been under the care of my friend Dr. Findlay, of Ha- 



580 DISEASES OF THE PERIPHERAL NERVES. 

vana, and who had been greatly relieved. Knowing nothing of Dr. 
Findlay's plan of treatment, I began a series of experiments to determine 
the best form of application and electrode, and after some trouble devised 
a method. 

An electrode was constructed, which is armed with two sponge-covered 
pads, one of which is connected with the positive pole of a galvanic bat- 
tery of twenty cells, while the other is attached to the negative wire of an 
induction coil. The double electrode is to be applied at the back of the 
neck, the two plates forming the terminal ends of the galvanic and fara- 
daic apparatus, and being insulated by a central plate of hard rubber. 
Any ordinary double electrode may be used, however, and will answer 
every purpose. The negative galvanic electrode is to be placed over the 
insertion of the sterno-cleido-mastoid muscle of the affected side, so that a 
descending current is sent through the contracted muscle, while upon the 
insertion of the muscle of the other side is placed a sponge-covered elec- 
trode attached to the positive wire of the induction coil. The antagonistic 
muscle is thereby subjected to the stimulation of an ascending current 
from the faradaic apparatus. 

Fig. 72. 




The treatment of these cases is suggested entirely by the physiological 
influence of the two currents upon muscular tissue. In wry-neck of the 
spastic variety there is of course on one side a condition of tonic spasm, 
while on the other side the antagonistic muscle is necessarily in a condition 
of lowered tone, subjected as it is to the strain imposed by the position of 
the head and by the unavoidable traction. It will be seen that the con- 
dition of the antagonist is worse even than that of an opposing muscle 
in some other part of the body where there is less mechanical strain or 
tension of parts, as in this case the weight of the head is a factor in the 
disease which prevents the opposing muscle from ever being properly 
subjected to the improving influence of treatment. 

A paralysis unaccompanied by contractures, and consequently 



TORTICOLLIS. 581 

with no permanent stretching of opponents is, as we well know, much 
more readily improved by electricity if the strain be removed by proper 
appliances — such, for instance, as the apparatus devised by Van Bibber 
and Detmold for lead and facial paralysis. In the case of wry-neck, it 
must be borne in mind that, as no apparatus can be suggested which will 
do more than tire out the vicious spasm of the contracted sterno-cleido- 
mastoideus (a therapeutical measure which I consider to be unphysiolog- 
ical, from the fact that the spasm is an evidence of deficient or irregular 
innervation), a procedure which will tend to diminish the irritability of 
the muscle in spasm, while increasing the energy and improving the nu- 
trition of the weakened opponent, is by far preferable. 

In many cases, I am convinced, there is an hysterical element, which 
is decidedly increased by forcible restraint ; and that this feature of the 
trouble belongs both to men and to women, I have no doubt. It is not diffi- 
cult to imagine that harsh or irritating treatment will do harm in such cases. 

In the varieties of wry-neck connected with disordered movements, 
there are several methods of treatment in vogue, which are sometimes 
successful. The ether-spray, either mediate or immediate (in the one case 
applied to the back of the neck ; in the other, to the muscles themselves 
for five minutes at a time), does good in some cases. In other cases the 
local injection of sulphate of atropia will markedly modify the spasm, 
while, in cases of great severity, decided doses of the tincture of gelseminum 
sempervirens or of hyoscyamia will diminish the violence of the sJDasmodic 
condition. A case mentioned by Radcliffe was treated with hypodermic 
injections of Fowler's solution, and improved somewhat. 

While I ain not disposed to take the grave view of the prognosis ex- 
pressed by Reynolds, it must be confessed that there are very many ex- 
amples which are not permanently benefited. Under this head come 
those which are unquestionably varieties of spinal or cerebral sclerosis. 
I have seen a case of progressive muscular atrophy which had been mis- 
taken for wry-neck. In cases of organic disease of the brain, the early 
history of the case and the connection perhaps with paralysis or contracture 
of the extremities show us that the case is not one of true torticollis. Ex- 
ceedingly rare cases of tonic contraction are met with in which the essen- 
tial condition is dislocation or disease of the cervical vertebrae. Then, of 
course, the prognosis is bad. 

The cases most readily helped are those dependent upon rheumatism or 
hysteria, and in such the prognosis is highly favorable. In the latter 
form of trouble, one or two applications of the faradaic current are alone 
sufficient, and, if the diagnosis is certain, it will be found that a shower 
of sparks, derived from a Holtz machine, directed upon the muscle, will 
favor a sudden disappearance of the spasm. 

A case of clonic spasm of the facial muscles of a very serious and per- 
sistent nature was cured by Baum, by nerve section. A slight paralysis 
of half an hour's duration was produced.^ 

1 Berliner Klin. Woch,, 1878, No. 40, and Bost. Med. and Surg. Journal, Sept. 4, 
1879, p. 341. 



582 DISEASES OF THE PERIPHERAL NERVES. 



PKOFESSIONAL CRAMP. 

Synonyms. — Writer's cramp, Dancer's cramp, Telegrapher's cramp ; 
Dyskin^sie professiouelle ; Melker-krampf, Schuster-krampf, Nahekrampf. 

This very interesting condition, which follows the overtraining of groups 
of muscles, is found among all who engage in occupations which require 
the exercise of particular voluntary muscles of the upper and lower ex- 
tremities to an excessive degree. Among these individuals such pro- 
tracted muscular action, especially when of a delicate kind, is likely to be 
followed by spasmodic movements such as would come under the first 
group of Mitchell. 

It is the first of the above varieties that at present interests us the 
most. 

Writer's Cramp is the form of hyperkinesis with which we are the 
most familiar, and it is difficult to fail in recognizing its true character. 
After continued and fatiguing use of the pen the hand may become at 
first tired; afterwards the patient suffers from sharp pains which run 
from the hand up the arm, while dull pains seated in the ball of the 
thumb, the dorsal aspect of the fingers, the wrist, or at the exposed por- 
tion of the ulnar nerve at the elbow, are to be found as well. His first 
intimation may be a certain tired feeling, or, as a very intelligent patient 
under my care expressed it, " The first idea of my trouble canie from the 
feeling that I had an arm. My mind was directed to it, and whether 
resting or at work, it felt like a clumsy part of my body." If the indi- 
vidual carefully forms his words, or if he " writes with his fingers " — a 
habit which schoolboys have, and which sometimes continues through 
life — the trouble is much more probable than when he uses his whole 
hand in guiding his pen. He may find after a while that when he at- 
tempts to write, the hand will fly upwards as the result of a spasm of the 
extensors and other muscles on the dorsal and ulnar side of the forearm, 
so that it is often impossible to form more than one or two words of a 
note before the trouble begins. 

This impaired writing power may exist to a lighter degree; but when the 
individual persists in his attempts, the convulsion is certain to take place. 
A light tonic spasm of the abductor mimimi digiti may occur when the 
little finger is separated from its fellows, and this is sometimes an early 
sign of the disease. He may educate the left hand to do the work of the 
right, and after a while may learn to use it in a satisfactory manner ; but 
very soon this too becomes affected, and he can write with neither hand. 
Other muscular movements are freely performed, and even some which 
closely resemble that of holding the pen. Trembling sometimes super- 
venes, while fibrillary muscular contractions are suggestive of the con- 
firmed disease. As is the case in sclerosis, the disorderly movements, or 
the spasms, seem to be intensified when the patient attempts to write in 
the presence of a looker-on, and he usually makes sad work. 



PROFESSIONAL CRAMP. 583 

The fingers, forearm, and wrist sometimes become the seat of lost 
power, and this is marked in the three first fingers of the right hand, and 
the pronators and supinators lose power. Sensation is rarely lost or im- 
paired. In some cases the flexors of the hand and the small muscles of 
the thumb are so weak that the point of the pen cannot be kept in contact 
with the paper, as the extensors seem to act independently. 

The same form of cramp afifects the thumbs and fingers of telegraphers, 
so that their work eventually becomes an impossibility. Onimus^ pre- 
sents a case. A telegraphic operator, 19 years of age, first experienced 
difficulty in making dots; " d " was made better than"u;" and it was 
found that when a line was first the dots were more easily made ; but let- 
ters like " h " or " p " were exceedingly difficult.^ 

Dancers' cramp has also been observed. Schultz^ describes this form 
of disease, of which he has seen three cases. It aflTects the solo dancers of 
the ballet as a rule, and the history of one case was the following : — 

" The patient complained of suflering very severe pains while dancing. 
Beginning in the soles of both feet, the pains spread with increasing 
severity to the calves of the legs ; they at last became so violent that her 
feeling of security was lost, the feet seeming as if made of wood. These 
pains were accompanied with violent palpitation ; and, if she continued to 
dance, she felt faint and sometimes lost consciousness, the body becoming 
quite rigid. When the pain and palpitation were less intense, the pain 
continued after dancing, and ceased very gradually, leaving some tender- 
ness of the soles ; on attempting again to dance the suflering would recur 
again. Dr. Schultz found, from the examination of these cases, that the 
cause of pain lay in the pas performed on the points of the feet, and is 
owing to exhaustion of the muscles which fix the metatarsus and pha- 
langes of the great toe. The shoe worn by the dancer, without which the 
ballet step seems to be impossible, is made as follows : The dancing-shoe 
is made rather wide; the sole is of soft leather, and shorter than the foot, 
reaching only as far as the posterior third of the ungual phalanx of the 
great toe. The upper part, generally of satin, projects forward, and sup- 
plies the place of the deficient leather of the sole. This part of the satin 
is worked threads, so that it may not be torn. In the interior of the 
shoe, over the leather sole, is a layer of thin, firmly-pressed pasteboard, 
either extending over the whole breadth of the anterior part, or limited 
to the length of the great toe. In the former case it is carried back, 
gradually narrowed as far as the heel. The leather sole and its cover- 
ing are lined with fine kid leather. The heel part of the shoe is quite 
soft, consisting only of satin ; and the shoe is fastened above the ankle 
by narrow ribbons. Without this preparation the pointed step is im- 
possible." 

I have met with the afiection among violin-players, and within the past 
year have had a patient under treatment. He had been diligently prac- 
tising a " run," which involved the necessity of complicated movements of 

1 Gaz. Med. de Paris ; Chicago Journal of Mental and Nervous Diseases, July, 
1875. 

2 ( u) ( d) (- - - - h ; p.) 3 Wiener Med. Woch. 



584 DISEASES OF THE PERIPHERAL NERVES. 

the fingers ; and it was his custom, on arising in the morning, to spend a 
half hour or so in playing the difficult passage; and on the day of the 
concert he worked for several hours at the same task, but upon attempt- 
ing to play in the evening he found it utterly impossible to do so, as his 
fingers would become rigid and refuse to obey the will. It was some 
months before he could again play. 

Onimus,^ in describing a form of impaired power and consequent mus- 
cular atrophy, which he calls " professional muscular atrophy," details a 
case which resembles somewhat the form of functional disease which we 
are considering. It begins by muscular cramp, and there is subsequent 
loss of power with wasting. I therefore think we may consider this aflTec- 
tion as a connecting link between scrivener's cramp and progressive mus- 
cular atrophy. He says : — 

" Recently I observed one case which it was most difficult to differen- 
tiate from progressive muscular atrophy, as the atrophied muscles were 
the same as those which are the first affected by this latter affection- 
They were the muscles of the thenar eminence, and chiefly the adductor 
pollicis. The patient was an enameller, who had to hold an object all 
day between his thumb and index finger. He first got cramps in the 
thumb, which suggested the idea of scrivener's palsy ; then tremor of the 
thumb, on account of the fibrillary contractions ; and, lastly, atrophy. 
Under the influence of treatment there was a rapid amendment, which 
showed that the case was really one of professional muscular atrophy, and 
not commencing progressive atrophy.'^ 

Causes and Pathology. — This spasmodic affection follows the con- 
tinued use of the muscles which are concerned in delicate muscular ac- 
tions ; and is not only produced by writing, but, as I have shown, by 
other forms of manipulation requiring great delicacy of co-ordination. 
The higher and the more complex is the character of these acts, and the 
more easily the faculty to perform them becomes developed, so much the 
greater is the danger of the disease. An act which requires at first men- 
tal direction of a superior kind, when acquired and executed uncon- 
sciously, is much more likely to give rise to this neurosis than one of a 
grosser kind, or one which is constantly performed under the active 
direction of the will. For this reason writer's cramp is much more rare 
among those who write and meanwhile compose, than among clerks or 
copyists who do " machine work." Constant use of the pen of this kind 
is seen to be followed by mischief. Such causes as piano-playing or violin - 
playing are by no means rare. A young lady, sent to me by my friend 
Dr. r>. M. Stimson, owed all her trouble to a bad habit she had contracted 
of reading novels while she practised her scales. In her case there was 
extensor paralysis, and some loss of sensation, which remained after a 
spasmodic stage. 

The conditions then, with the exception of paralysis, are the result of 
an over-developed automatism, and are not, I am convinced, connected 

1 London Lancet, Jan. 22, 1876. 



PROFESSIONAL CRAMP. 585 

with any central change, though Mr. Solly ^ is inclined to consider that 
there is degeneration of the motor cells in the upper part of the cord. 

In writing a familiar word, or collection of words, the educated indi- 
vidual does not stop to form every letter, but the pen is unconsciously 
guided. It is even possible to talk while writing or playing the piano, 
and equally complex feats are performed while the mind is not engaged. 
In many of these acts the volition is directed in other channels, or is 
behind the muscular action. The pen travels in advance of the mind; 
and should this state of things be so exaggerated as to become more than 
a phase of the ordinary automatism which enters into the performance 
of many of the functions of daily life, there remains condition of dis- 
ordered and heightened activity which is uncontrolled by the will, and is 
symptomatized by the spasms of which I have spoken. A more advanced 
condition consists in exhaustion of the motor cells at the upper part of 
the cord, and as a result we find loss of power and occasionally atrophy. 
Poore^ does not believe in the central organic origin of the disease; but 
Solly, * Smith, * and others take this view of the case. 

Among 24 cases which I have seen, the occupation of the individuals 
was as follows : — 



Clerks . 


. . 14 


Stenographer . 


. . 1 


Engraver 


. 1 


Musicians . 


. . 3 


T;awyers 


. 2 


Type-setter 


. . 1 


Clergymen 


. 1 


Cigar-maker 


. . 1 



The patients were all men but one, and with this exception were be- 
tween the ages of 30 and 60 ; I do not believe, however, this latter fact 
has very much importance. 

Diagnosis. — Progressive muscular atrophy may be mistaken for the 
paralytic form, but when it is remembered that the paralysis precedes 
the atrophy (should such tissue-change take place), and that progressive 
muscular atrophy is rarely so limited, there is no reason why the real 
nature of the trouble should not be recognized. Neuralgia of the cervi- 
co-brachial variety is a common symptom, and its real significance may 
not be detected ; the subsequent element of spasm, tremor, or paralysis 
will, however, remove any doubt from the mind of the observer. 

Prognosis. — If the individual gives up the occupation which has 
produced the affection, there is no reason why he should not recover, 
provided the disease has not become confirmed, and even in this form 
Jaccoud^ speaks of a rare temporary amelioration. It has been my 
experience that, if taken in hand promptly, the patient may be cured. 
Sixteen of these cases were absolutely cured, and continued so as long as 

A Surgical Experiences, London, 1865, p. 205. 

2 Practitioner, June, July, and August, 1873. 

» Op. cit. 

-^ Lancet, March 27, 1869. 

5 Op. cit., p. 302. 



586 DISEASES OF THE PERIPHERAL NERVES. 

they refrained from their work. Two were improved, but upon begin- 
ning the pursuit of their calling had relapses. The remainder were of 
the paralytic variety, and have been for some time under treatn^ent. 

Treatment. — Rest and electricity are the means at our command. 
A galvanic current is found to be the most beneficial, and the electrodes 
should be so small as to include but one muscle at a time in the circuit. 
The current must be mild, or it will only aggravate the disease. Besides 
this application to special muscles, one pole may be placed at the nape of 
the neck, and the other to the muscles of the hand and forearm. 

A. W., aged 38. The patient had followed the occupation of clerk for 
several years, and had assiduously worked at his desk for many hours 
in the day. Two weeks before I saw him he noticed an impairment in 
his writing power, and this consisted in an inability to write without the 
occurrence of a convulsive contraction of the extensors of his right fore- 
arm, by which the pen flew from the paper. This did not occur at the 
moment of writing, but after a few words had been finished. He tried 
to keep the hand steady by the influence of the will, but all his eflbrts 
were iueflectual. When he attempted to hold the point of any small ob- 
ject, such as a stick or pencil, against the surface, the same spasm would 
occur. There was no wasting of the muscles, pain, or other symptom. 
I determined to try galvanism combined with manual exercise, and the 
internal application of strychnia in doses of 21th of a grain. Galvaniza- 
tion of the flexors of the forearm and of the small muscles of the hand 
was made, and, at the same time, the positive pole was held for a few 
minutes at the nape of the neck. He was directed to procure the rounds 
of a chair with which to exercise. Galvanization was persevered in, 
although the progress was very slow. At first he could not write more 
than two words (almost illegibly) ; but as he grew better, these spasms 
disappeared. 

Three seances a week kept up for a period of about three months eflect- 
ed such an improved condition that he was finally discharged at the end 
of that time. 

Strychnia and iron, or conium, are remedies which may be used in 
conjunction. The ether spray apparatus does great good, and I have 
occasionally benefited my patients by fastening the hand in an immova- 
ble apparatus or splint. Absolute cessation of the particular work which 
gave rise to the malady is to he insisted upon, and no benefit will result 
from any form of treatment unless this command of the physician is 
r espected. 

When the patient attempts writing anew he should provide himself 
with a pen having a cork holder, and this may be purchased from any 
good stationer. He should change his system of penmanship and acquire 
the so-called free hand style, in which the fingers are engaged only in 
holding the pen, and the other motions are performed by the muscles of 
the forearm. The attempt at "shading" the lines should not be made 
but he should endeavor to adopt the round hand and avoid "pot hooks" 
and "up and down" strokes as much as possible. 



CESOPHAGISMUS. 587 

Sea air, salt baths, and a change of habits and scene are all fraught 
with benefit. 

I do not consider tenotomy advisable except in extreme instances. 

CESOPHAGISMUS. 

A comparatively rare neurosis often met with among women consists in 
a spasmodic contraction of the oesophagus. It is usually hysteroid in 
character, or may be the reflex result of a simple stomatitis, beginning, 
perhaps, in a trivial irritation of the food passage ; and giving the indivi- 
dual little annoyance at first, it may develop into a condition causing 
great misery and suffering from dysphagia, so that she may be unable to 
swallow anything but fluids, and these in small quantities, and most 
easily when they are warm. 

" Tightness of the throat," the globus hystericus and, more or less, 
hyper sesthesia, may be symptoms which precede or accompany- the 
trouble. 

There is emotional derangement as well, and the patient weeps and is de- 
spondent. The symptoms of spinal irritation may or not be manifested, 
and there is usually some spinal tenderness. A patient sent to me by Dr. 
Cohen, of Philadelphia, had suflered for several years, and I have exa- 
mined other patients who have suffered even longer. The discomfort at- 
tending the local trouble aflfects the general condition, and malnutrition 
from insufficient food and sleeplessness reduce the patient in every way. 
An examination, by means of an olive-pointed bougie, will immediately 
apprise us of the cause of the annoyance, and among hysterical women, 
who complain of their inability to swallow, we will often find, by local 
examination, that there is a true oesophageal spasm, which is sufficient to 
account for the subjective expressions some of us are inclined to disre- 
gard. 

I have met with subjects who complained of a spasm of the upper 
part of the pharynx with sharp pain, and in several instances have traced 
its origin to the immoderate use of tobacco. 

Treatment. — The affection is a troublesome and persistent one. 
Galvanization of the sympathetic ; local treatment by bougies and ether 
spray to the back of the neck are important external remedies ; while we 
may give internally, hysocyamia or any of the anti-spasmodics before 
alluded to. 



THE END. 



INDEX 



ABORTED epilepsy, 390 
Abscess of cerebellum, 229 
Absence of blood in cutaneous vessels in 

hysteria, 457 

of "tendon reflex" in locomotor 
ataxia, 322 
Abstinence from food in hysteria, 461 
Abuse of bromides in epilepsy, 408 
Active cerebral hyperemia, 76 
Acute alcoholism, 430 

cerebral anosmia, 127 

cerebritis, 165 

myelitis, 265 

softening, 164 
Acute ascending paralysis, 275 

synonyms of, 275 

definition of, 275 

symptoms of, 275 

causes of, 276 

pathology of, 276 

diagnosis of, 277 

prognosis and treatment of, 277 
Acute cerebral meningitis, 48 

symptoms of, 48 

causes of, 49 

pathology and morbid anatomy of, 50 

prognosis and treatment of, 54 
Acute granular (tubercular meningitis), 58 

symptoms of, 58 
Acute and chronic spinal meningitis, 236 

symptoms of, 236 

causes of, 240 

morbid anatomy of, 241 

prognosis of, 242 

treatment of, 243 
Adult spinal paralysis, 287 
.-Esthesiometer, the, 25 

Sieveking's, 26 
Afi'ections of the organs of speech in cho- 
rea, 484 
Agraphia, 183 
Albuminuric aphasia, 198 
Alcohol in urine, means of detecting, 437 

in ventricular fluid, 435 
Alcoholism, 430 

acute. 430 



Alcoholism [continued) 
causes of, 434 
chronic, 432 
definition of, 430 
diagnosis of, 437 
hallucinations in, 431 
morbid anatomy and pathology of, 

435 
prognosis of, 437 
symptoms of, 430 
treatment of, 438 
Amblyopia as a symptom of brain tumor, 

209" 
Amidon on tetanus, 378 
Anaemia, cerebral, 127 

spinal, 259 
Ansesthesia, 542 
causes of, 542 

diagnosis and prognosis of, 544 
of fifth nerve, 543 
hysterical, 457 
of radial nerve, 449 
symptoms of, 542 
treatment of, 544 
Angular gyrus, functions of, 194 
Aneurism of cerebellum, 229 

miliary, 113 
Antero-lateral amyotrophic sclerosis, 342 
causes of, 345 
diagnosis of, 346 
morbid anatomy of, 345 
prognosis of, 346 
symptoms of, 342 
synonyms of, 342 
treatment of, 346 
Antero-spinal paralysis of adults, 237 
causes of, 291 
definition of, 287 
diagnosis of, 292 
morbid anatomy and pa- 
thology of, 292 
prognosis of, 292 
symptoms of, 287 
synonyms of, 287 
treatment of, 294 
of infants, 277 

589 



590 



INDEX. 



Antero-spinal paralysis {continued) 
causes of, 281 
definition of, 277 
deformities in, 279 
diagnosis of, 285 
electricity in, 285 
morbid anatomy and pa- 
thology of, 282 
muscular tissue, changes in, 

284 
prognosis of, 285 
Sinkler's cases of, 278 
symptoms of, 278 
synonyms of, 277 
treatment of, 285 
Aphasia, 179 

children, of, 194 
definition of, 179 
diagnosis of, 195 
history of, 180 
infantile, 194 

location of speech centre in, 186 
Lordat on, 182 
medico-legal study of, 197 
of Dr. Aliin, 193 
synonyms of, 179 
treatment of, 199 
with left sided paralysis, 189 
Apoplexy, 90 
Apparatus, electrical, 34 

for the treatment of nervous diseases, 
34 
Arthropathies in locomotor ataxia, 325 
Ascending degeneration of posterior col- 
umns, 341 
Asemasia, 179 
Asphyxie locale, 544 
Atheromatous changes in vessels, 113 
Athetosis, 99 

Atrophy, partial facial, 308 
causes of, 310 
diagnosis of, 310 
Draper's case of, 308 
pathology of, 310 . 
prognosis of, 310 
synonyms of, 308 
symptoms of, 308 
treatment of, 311 
of cerebellum, 225 
progressive muscular, 295 
Auditory vertigo, 139 - 
causes of, 141 
definition of, 139 
diagnosis of, 143 
pathology of, 141 



Auditory vertigo (continued) 

synonyms of, 139 

treatment of, 143 
Auditory epilepsy, 400 
Automatic man, the, 390 

BASEDOW'S disease, 503 
Basilar meningitis, 58 
Bed-sores, 268 
Bell's paralysis, 549 
Benzine cautery, the, 37 
Bilateral facial paralysis, 549 
Blanching of fingers, 544 
Bloodletting in apoplexy, 123 
Blue line, the, 566 
Bone changes in posterior spinal sclerosis, 

325 
Brain, inflamm.ation of. 164 

red softening of, 170 

syphilitic disease of, 173 
tumors, 205 

choked disk a symptom of, 208 

diagnosis of, 219 

localization of, 220 

morbid anatomy of, 211 

prognosis, 222 

symptoms of, 205 

treatment of, 223 
Brittleness of bones in locomotor ataxia. 

326 
Bromides in epilepsy, 405 
Bulbar diseases, 384 
paralysis, 414 

causes of, 418 

diagnosis of, 420 

morbid anatomy and pathology 
of, 418 

prognosis of, 420 

progressive variety of, 417 

reflex variety of, 417 

stationary variety of, 417 

symptoms of, 415 

synonyms of, 414 

treatment of, 420 

CANCEROUS growths in brain, 212 
Case of cerebellar tremor, 227 
ofDr. Allm, 193 
of post-paralytic chorea, 98 
Catalepsy, 479 
causes of, 480 
definition of, 479 
diagnosis of, 482 
flexibilitas cerea in, 480 
induced in animals, 482 



INDEX 



591 



Catalepsy (continued) 
malarial, 480 
morbid anatomy and pathology of, 

4S1 
prognosis of, 482 
symptoms of, 479 
treatment of, 482 
Catlin's observations, 527 
Cauteries, 36 
author's, 36 
glass rod, 36 
Guerard's, 37 
Pacquelin's, 37 
Central neuritis, 208 

spinal hemorrhage, 251 
Centre, auditory, 194 
Cerebral anaemia, symptomatic, 127 

causes of, 130 

chronic, 128 

definition of, 127 

infantile, 129 

morbid anatomy and pathology 
of, 132 

prognosis of, 135 

symptoms of, 128 

synonyms of, 127 

treatment of, 135 
congestion, 76 
hemorrhage, 90 

attacks of, without loss of con- 
sciousness, 94 

causes of, 101 

condition of eyes in, 93 

conjugate deviation of eyes in, 93 

definition of, 90 

diagnosis of, 115 

morbid anatomy and pathology 
of, 104 

post-paralytic states in, 98 

prodromata of, 90 

prognosis of, 119 

psychical disturbance in, 92 

residual paralysis in, 95 

respiratory disturbance in, 93 

seat of, 115 
- symptoms of, 90 

tendon reflex in, 100 

time of attack of, 103 

treatment of, 122 
hyperismia, symptomatic, 76 

causes of, 77 

definition of, 76 

diagnosis of, 86 

morbid anatomy of, 85 

pathology of, 83 



I Cerebral hyper^emia, symptomatic, {con- 
I tinned). 

j prognosis of, 88 

symptoms of, 77 
j synonyms of, 77 

I treatment of, 88 

meninges, diseases of, 38 
meningitis, acute, 48 
causes of, 49 
diagnosis of, 50 
pathology and morbid ana- 
tomy of, 50 
prognosis of, 54 
symptoms of, 48 
treatment of, 54 
chronic, 71 

treatment of, 75 
pachymeningitis, 38 

acute, symptoms of, 40 
chronic, causes of, 43 

morbid anatomy and patho- 
logy of, 43 
osseous plates in, 43 
prognosis of, 44 
symptoms of, 40 
treatment of, 44 
with hgematoma, 44 
case of, 46 
causes of, 45 
formation of cysts in, 45 
morbid anatomy and pa- 
thology of, 45 
prognosis of, 48 
symptoms of, 44 
treatment of, 48 
rheumatism, 55 
sclerosis, 199 

causes of, 203 
definition of, 199 
difhised, 199 
diagnosis of, 204 
prognosis of, 204 
symptoms of, 200 
synonyms of, 199 
treatment of, 204 
softening, 164 
acute, 165 

causes of, 167 
diagnosis of, 168 
morbid anatomy and pa- 
thology of, 167 
prognosis of, 169 
symptoms of, 165 
treatment of, 169 
chronic, 170 



592 



INDEX. 



Cerebral softening, chronic, [continued) 
causes of, 173 
definition of, 170 
diagnosis of, 177 
morbid anatomy and pa- 
thology of, 174 
prognosis of, 178 
symptoms of, 170 
treatment of, 179 
classification of, 164 
definition of, 164 
thermometry, 23 

tumors, Grasset's classification of, 211 
localization of, 220 
Cerebellum, tumors of, 225 
softening of, 229 
abscess of, 229 
atrophy of, 225 
tumors of, 226 
hemorrhage of, 225 
Cerebellar disease, 223 

diagnosis of, 234 
prognosis of, 234 
treatment of, 235 
Cerebritis, 165 
Cerebro-spinal diseases, 421 
meningitis, 421 

retraction of head in, 422 
Cerebrum and cerebellum, diseases of, 76 
•Cervical pachymeningitis, 238 
Cervico-brachial neuralgia, 519 
Cervico-occipital neuralgia, 518 
Character of the deposit in so-called 

tubercular meningitis, 66 
Charcot on reduced temperature in hys- 

tero-epilepsy, 479 
Chloral-bromide treatment in epilepsy, 

408 
Choked disk, 208 
Chorea, 483 
adult, 488 

among school children, 491 
causes of, 490 
definition of, 483 
dependent upon tapeworm, 486 
diagnosis of, 495 
embolic theory of, 491 
epidemic, 483 

ether spray in treatment of, 496 
heart lesions of, 492 
irregular forms of, 486 
hyoscyamia in, 497 
malarial, 491 

morbid anatomy and pathology of, 
491 



Chorea (continued) 

of pregnancy, 488 
post-paralytic, 98 
prognosis of, 496 
rare among negroes, 490 
symptoms of, 484 
synon5^ms of, 483 
treatment, 496 
with eczema, 490 
Chronic cerebral pachymeningitis with 
hsematoma, 44 
myelitis, 269 
Circulation of brain, Duret on. 111 

alcoholism, 432 
Clavus hystericus, 455 
Color blindness, 441 
Columns of Gall, sclerosis of, 341 
Condition of organs of generation in hys- 
teria, 455 
Congestion, cerebral, 76 

spinal, 255 
Congestive pernicious fever, its resem- 
blance to cerebro-spinal meningitis, 424 
Constriction band, the, 269 
Contractions, fibrillary, 296 

of muscles in cerebro-spinal menin- 
gitis, 422 
Contractures in antero-lateral sclerosis, 
342 
in hemiplegia, 98 
in infantile paralysis, 279 
in hysteria, 459 
Contusions and punctured wounds as 

causes of paralysis, 555 
Convulsion as symptom of brain tumor, 

205 
Corpuscles, Gluge's, 175 
Cramp, dancer's, 582 
telegrapher's, 682 
writer's, 582 
professional, 582 
causes of, 584 
diagnosis of, 585 
pathology of, 584 
" Crises gastriques," 328 
Cross paralysis, 115 
Crum-Brown's experiments, 140 
Cutaneous eruptions in locomotor ataxia 

325 
Cutaneous eruptions in neuritis, 539 

DA COSTA on cerebral rheumatism, 56 
Decubitus paralysis, 557 
Decussation of optic fibres, 209 
Delirium tremens, 430 



INDEX, 



593 



Depraved appetite m hysteria, 456 
Diathetic growths, 212 
Diphtheritic paralysis, 562 
Diseases of cerebral meninges, 38 

of cerebrum and cerebellum, 76 

of lateral columns, 347 
Dislocation as a cause of paralysis, 555 
Disseminated sclerosis, 424 
Division of a nerve trunk as a cause of 

paralysis, 560 
Dorsal-clonus, 350 
Douleureux, tic, 513 
Dynamometer, 28 

Mathieu's, 29 

the author's, 30 

ECHOLALIA, 196 
Eczema with chorea, 490 
Education of right side of brain, 199 
Electrical apparatus, 34 
Embolism, 154 

of the cerebral vessels, 154 
causes of, 157 
diagnosis of, 158 
morbid anatomy and pa- 
thology of, 161 
prognosis of, 163 
symptoms of, 154 
treatment of, 163 
Endemic tetanus, 374 
Endoarteritis, syphilitic, 177 
Epidemic chorea, 483 
Epilepsy, 384 
aborted, 390 

abuse of bromides in, 406 
age in causation of, 393 
auditory, 400 

Brown-Sequard's experiments in, 398 
causes of, 393 

condition of pupils in, 392-403 
definition of, 384 
diagnosis of, 402 
dislocation of bones in, 388 
experimental production of, 398 
grave attacks of, 385 
heredity in, 394 
history of, 384 
hystero, 470 

induration of cornua ammonis, 396 
irregular attacks of, 390 
Jackson on, 399 
light attacks of, 389 
masked; 390 

morbid anatomy and pathology of, 
396 

38 



Epilepsy (continued) 
nocturnal, 388 
prognosis of, 403 
responsibility in, 392 
symptoms of, 385 
synonyms of, 384 
syphilitic, 403 

temperature influences in, 394 
tongue biting in, 387 
treatment of, 404 
warnings in, 385 
Epileptiform tic, 513 

hysteria, 470 
Equilibrium, sense of, the, 334 
Erotogenetic zones, 479 

with locomotor ataxia, 325 
'Essential paralysis, 287 
Etat crible, the, 85 
Examination of pupils, 33 

post-mortem, 18 
Exhaustion simulating acute tubercular 

meningitis, 70 
Exophthalmic goitre, 503 
causes of, 508 
definition of, 503 
diagnosis of, 509 
morbid anatomy and pathology 

of, 508 
prognosis of, 509 
symptoms of, 503 
synonyms of, 503 
treatment of, 509 
skin changes in, 506 



F 



ACIAL neuralgia, 513 
paralysis, 549 



causes of, 550 

diagnosis of, 552 

electricity in, 553 

pathology of, 551 

prognosis of, 553 

symptoms of, 549 

synonyms of, 540 

treatment of, 553 

wire hook in treatment of, 553 
spasm without pain, 556 
Faradic apparatus, 34 
Fibrillary contractions, 296 
Flechsig's investigations, 361 
Flexibilitas cerea, 480 
Function of angular gyrus, 194 
Functional disease of lateral columns, 354 



p ALVANIC batteries, 34 
VJI General paresis, false, 173 



594 



INDEX. 



Gibney on traumatic causation of spinal 

irritation, 259 
Glass rod cautery, 36 
Gliomata of brain, 213 
Globus hystericus, the, 462 
Gluge's corpuscles, 175 
Goitre, exophthalmic, 503 
Grasset's classifica ion of brain tumors, 211 
Graves' disease, 503 
Griffin on spinal irritation, 259 

HARDENING fluids, 20 
Hemiplegia, 95 

hysterical, 458 
Hemorrhage, cerebral, 90 
meningeal, 115 
spinal, 251 
cerebellar, 225 
Heredity in pseudo-hypertrophic paraly- 
sis, 317 
High temperature in tetanus, 372 - 
Hints in regard to methods of examina- 
tion and study, 17 
Holland on leeching, 54 
Hydrobromic acid, 89 
Hydroiodic acid in goitre, 510 
Hydromyelia, 360 
.Hydrophobia, 444 
causes of, 450 
curare in, 454 
diagnosis of, 453 
:Dr. Hadden's case of, 445 
morbid anatomy and pathology of, 

450 

prognosis of, 454 

•symptoms of, 444 

- synonyms of, 444 

treatment of, 454 

! Hysteria, 454 

causes of, 463 

definition of, 454 

diagnosis of, 467 

in children, 463 

morbid anatomy and pathology of, 

466 
prognosis of, 468 
symptoms of, 455 
treatment of, 468 
; Hysterical anesthesia, 457 
ataxia, 337 
contracture, 459 
eye troubles, 458 
, hemiplegia, 460 
paraplegia, 458 
spasmodic spinal paralysis, 355 



Hystero-epilepsy, 470 
symptoms of, 471 
treatment, 479 

INFANTILE hemiplegia, 277 
hysteria, 463 
paralysis, 277 
spasmodic paralysis, 353 
Inflammation of spinal cord, 265 
Instruments used for the diagnosis of 

nervous diseases, 22 
Intra-cranial vessels, embolism of, 145 
Intra-vesical troubles in myelitis, 265 
Irritation, spinal, 259 
cause of, 261 
diagnosis of, 263 
morbid anatomy and pathology of, 

262 
prognosis and treatment of, 265 

TACKSON on epilepsy, 399 

LATERAL columns, hysterical disease 
of, 355 
Lateral sclerosis of the spinal cord, 347 
diagnosis of, 368 
morbid anatomy of, 360 
prognosis of, 368 
symptoms of, 347 
synonyms of, 347 
treatment of, 369 
Lead poisoning, 566 
causes of, 568 
diagnosis of, 572 
morbid anatomy and pathology 

of, 571 
prognosis of, 572 
synonyms of, 566 
treatment of, 572 
Lesions in epilepsy, 397 
Local paralysis, 548 
Localization of tumors, 220 

of cerebellar disease, 233 
of cerebral hemorrhage, 104 
Locomotor ataxia, 321 
hysterical, 337 

MAIN en griffe, 296 
Male hysteria, 462 
Mastodynia, 523 
Meniere's disease, 139 
Meningeal hemorrhage, 115 
Meningitis, acute and chronic spinal, 230 
symptoms of, 236 
granular, 58 



INDEX, 



595 



Meningitis {continued) 
cerebro-spinal, 421 
causes of, 423 
definition of, 421 
diagnosis of, 423 
morbid anatomy and pathology 

of, 423 
prognosis of, 424 
symptoms of, 421 
synonyms of, 421 
treatment of, 424. 
chronic cerebral, 71 
causes of, 74 
diagnosis of, 74 
morbid anatomy and pa- 
thology of, 74 
prognosis of, 75 
symptoms of, 71 
treatment of, 75 
of the aged, 57 
rheumatic, 55 
senile, 57 

tubercular (granular), 58 
basal, 58 
causes of, 63 
development of, 63 
diagnosis of, 68 
morbid anatomy and pathology 

of, 65 
prognosis of, 68 
symptoms of, 58 
treatment of, 70 
tubercular deposits in, 65 
vertical, 63 
Meningo-cerebritis, 165 
Mental changes in locomotor ataxia, 327 
Migraine, 513 
Miliary aneurisms, 113 
Mimetic chorea, 483 
Morbid impulses in hysteria, 456 
Mortality in tubercular meningitis, 64 
Mottled skin in pseudo-hypertrophic pa- 
ralysis, 312 
Multiple embolism, 161 
Muscular rheumatism, 541 
Myelitis, 265 

causes of, 270 

chronic, 269 

diagnosis of, 272 

morbid anatomy and pathology of, 

271 
prognosis of, 274 
symptoms of, 269 
treatment of, 274 
vesical troubles in, 268 



NERVES, tumors of, 547 
Nerve-stretching, 534, 541 
Neuralgia, age and sex in causation of 
524 
association with epilepsy, 524 
bad teeth as a cause of, 526 
causes of, 524 
cervico-occipital, 518 
brachial, 519 
circulatory disturbances in, 512 
clavus, 515 

coarse and fi.ne varieties of, 531 
crural, 522 
definition of, 511 
diagnosis of, 528 
electricity in treatment of, 534 
excision of supra-orbital in, 516 
facial, 513 

influence of temperature in, 527. 
intercostal, 520 
inveterate, an, case of, 529 
morbid anatomy of, 528 
nerve areas in, 532 
nerve section in, 516 
of testis, 523 
ovarian, 523 
prognosis of, 529 
renal, 523 
sciatic, 520 
syphilitic, 525 
treatment of, 531 
trigeminal, 513 
trophic disturbances in, 512 ' 
urethral, 523 

Granville's apparatus in, 528 
visceral, 522 
Neuritis, 538 

causes of, 540 

morbid anatomy and pathology of,., 

540 
nerve section in, 541 

stretching in, 541 
prognosis of, 541 
symptoms of, 538 
treatment of, 541 
trophic changes in, 538 
Neuromata, sarcomatous, 547 

treatment of, 547 
Nicotinism, 439 
causes of, 442 

prognosis and treatment of, 443 
symptoms of, 440 
Nystagmus, 189 



596 



INDEX. 



OCCLUSION of intracranial vessels, 145 
Occupation, and its relation to cere- 
bral hypersemia, 81 
Ocular trouble with brain tumor, 208 

in locomotor ataxia, 323 
(Esopbagismus, 587 
Ophthalmoscope, the, 30 
Opisthotonos, 371 

Organs of speech, affection of in chorea, 
484 



PACHYMENINGITIS as a result of 
injury, 38 
cerebral, 38 
spinal, causes of, 238 

diagnosis of, 243 

morbid anatomy and pathology 
of, 241 

prognosis of, 242 

symptoms of, 236 

treatment of, 243 
with hasmatoma, 44 
Painters' colic, 566 
Palsy, Scrivener's, 582 
shaking, 498 
wasting, 295 
Paralysis, adult spinal, 287 
acute ascending, 275 
after dislocation, 555 
agitans, 498 

case of, 49& 

causes of, 500 

diagnosis of, 501 

morbid anatomy and pathology 
of, 500 

prognosis of, 502 

symptoms of, 498 

synonyms of, 498 

treatment of, 502 
antero-spinal, of infancy, 277 
bulbar, 414 
cross, 115 
Cruveilhier's, 295 
diphtheritic, 562 

causes of, 564 

diagnosis of, 565 

morbid anatomy and pathology 
of, 564 

prognosis of, 565 

symptoms of, 562 

treatment of, 565 
facial, 549 

from pressure of forceps, 556 
heat in the treatment of, 126 



Paralysis (continued) 
hysterical, 460 
local, 548 
of sphincters, 268 
pseudo-hypertrophic, 311 
residual, 95 
temporary spinal, 291 
traumatic, 555 
Paralytic chorea, 485 
Paraplegia, 267 

hysterical, 460 
Paresis, general, 173 
Parkinson's disease, 498 
Partial celebral anaemia, 145 
Partial facial atrophy, 308 
Passive cerebral hyperemia, 77 
Percussion hammer, 33 
Percuteur, the, 535 
Perivascular spaces, the, 86 
Petrina on localization, 220 
Pleurodynia, 520 
Pleurosthotonos, 371 
Poisoning, lead, 566 
Posterior spinal sclerosis, 321 

ascending and descending, 

322 
causes of, 329 
diagnosis of, 336 
morbid anatomy and patho- 
logy of, 330 
neuralgia in, 321 
periods of improvement in, 

339 
prognosis of, 338 
state of mind in, 327 
symptoms of, 321 
synonyms of, 321 
treatment of, 339 
Post-hemiplegic disorders of movement, 98 
Post-paralj^'tic chorea, 98 
Primary and compensato-ry contractions 

in paralysis, 279 
Primary degeneration of lateral columns, 

356 
Prodromata of infantile palsy, 277 
Professional cramp, 582 

muscular atrophy, 486 
Prognosis in syphilitic brain disease, 179 
Progressive muscular atrophy, 295 
causes of, 299 
definition of, 295 
diagnosis of, 304 
history of, 295 
morbid anatomy and patho- 
logy of, 301 



INDEX, 



597 



Progressive muscular atrophy (continued) 

prognosis of. 307 

resembling lead palsy, 304 

skin changes in, 299 

symptoms of, 295 

synonyms of, 295 

treatment of, 307 
Progressive Paresis and locomotor ataxia, 

326 
Pseudo-hypertrophic muscular paralysis, 

311 

cases of, 271 

causes of, 317 

diagnosis of, 319 

heredity in, 317 

lordosis in, 315 

pathology and morbid ana- 
tomy of, 318 

prognosis of, 320 

symptoms of, 311 

synonyms of, 311 

treatment of, 320 
Puerperal embolism, 158 
hysteria, 464 

T) ABIES canina, 444 

JAj Red softening, 170 

Eeflex spasm, 577 

Retraction of head in cerebro-spinal me- 
ningitis, 422 

Rheumatic meningitis, 55 

Eisus sardonicus, 370 

Romberg on delayed transmission of pain- 
ful impressions, 269 

Rubber muscle, the, 35 

SCIATICA, 520 
Sclerosis, antero-lateral, 342 
cerebral. 199 
diffused, 200 
of columns of Goll, 341 
cerebro-spinal,^ 424 
causes of, 425' 
diagnosis of, 429- 
morbid anatomy and pathology 
■ of, 429 
prognosis of, 429- 
symptoms of, 425 
synonyms of, 424 
treatment of, 429 
disseminated, 424 
lateral, 317 

deformity of feet in, 357 
posterior-spinal, 321 
Sclerose en plaques, 424 



Scrivener's palsy, 582 
Seat of cerebral hemorrhage, 115 
Secondary degeneration of lateral col- 
umns, 99 
Senile meningitis, 57 
Seventh nerve, paralysis of, 549 
Shaking palsy, 498 
Sieveking's ©sthesiometer, 22 
Sleep not necessarily due to cerebral anae- 
mia, 134 
Softening after vascular plugging, 145 
cerebral, 164 
cerebellar, 229 

not necessarily an inflammatory pro- 
cess, 164 
of posterior columns in tetanus, 378 
Spaces, the perivascular, 86 
Spasm, facial, without pain, 576 
from genital irritation, 577 
functional, 576 

with voluntary movements, 576 
pathology of, 579 
reflex, 577 
treatment of, 579 
Spasmodic spinal paralysis, 356 
Spinal ansemia, so called, 259 

Gibney on traumatic causation 

of, 259 
Griffin on, 259- 
congestion, 255 

symptoms of, 259 
hemorrhage, 251 
causes of, 252 
diagnosis of, 254 
morbid anatomy and pathology 

of, 253 
prognosis of, 254 
symptoms of, 251 
synonyms, 251 
treatment of, 254 
hypersemia, subacute, 256 
causes of, 256 
diagnosis of, 257 
morbid anatomy and patho- 
logy of, 257 
prognosis of, 258 
symptoms of, 256 
treatment of, 258 
irritation, 259 

causes of, 261 

diagnosis of, 263 

morbid anatomy and pathology 

of, 262 
prognosis of, 263 
symptoms of, 259 



598 



INDEX. 



Spinal irritation (continued) 
treatment of, 263 
meninges, diseases of, 236 
meningitis, acute and chronic, 236 
pachymeningitis, 238 
causes of, 240 
symptoms of, 238 
paralysis, temporary, 251 
tumor, 245 

causes of, 250 

diagnosis of, 250 

morbid anatomy and pathology 

of, 250 
prognosis of, 250 
symptoms of, 245 
treatment of, 251 
varieties of, 245 
Spotted fever, 421 
Staining solutions, 21 
Sthenic cerebral hyperemia, 77 
Stomachic vertigo, 138 
St. Vitus' dance, 483 
Sulphur baths in locomotor ataxia, 340 
Syncope, 127 

Syphilis of the brain, 173, 179 ' 
Syphilitic encephalopathie, 177 
epilepsy, 403 
myelitis, 270 
" neuralgia, 525 
" pachymeningitis, 41 

TABES dorsalis, 321 
Tache cerebrale, 61 
Tarantism, 484 

Temporary spinal paralysis, 291 
Tendon-reflex, absent, 322 

in lateral sclerosis, 358 
method of testing, 34 
Tetanoid paraplegia, 356 
Tetanus, 370 

allied to strychnia poisoning, 379 

causes of, 373 

curare in, 382 

chloral hydrate in, 382 

definition of, 370 

diagnosis of, 380 

endemic, 374 

morbid anatomy and pathology of, 
377 

nascentium, 373 

on Long Island, 374 

pleurosthotonos in, 371 

prognosis of, 381 

risus sardonicus in, 370 

softening of posterior columns in, 378 

statistics of, 374 

symptoms of, 370 



Tetanus (continued) 
synonyms of, 370 

rise of temperature in, 372 
treatment of, 381 
urine in, 372 
Tetany, 576 
The epileptic zone, 398 
Theory of sleep, 134 
Thermometer, the, 22 
Thermometry, cerebral, 23 
Thrombosis, 145 

of cerebral arteries, 146 
causes of, 149 
diagnosis of, 151 
morbid anatomy and patho- 
logy of, 149 
treatment of, 151 
of sinuses and veins, 151 

after aural disease, 153 
Tic douleureaux, 513 
Tobacco amblyopia, 441. 
Tonga, 536 
Torticollis, 578 
Transposition in aphasia, 183 
Traumatic paralysis, 555 
diagnosis of, 559 
prognosis of, 559 
treatment of, 560 
Treatment of bed-sores, 274 
Tremor, 17 

functional, 576 
Tri-nitro glycerine, 413 
Trismus nascentium, 373 
Trophic changes in traumatic paralysis, 

560 
Tumors of brain, 205 
of cerebellum, 226 
of nerves, 546 
spinal, 245 

UNILATERAL tremor as a result of 
localized meningitis, 50 
Urine in tetanus, 372 

VARIATIONS of temperature in cere- 
bral hemorrhage, 94 
Vertigo, 139 

" stomachic, 138 
Visual word centre, 194 

WIRE hook in treatment of facial 
paralysis, 553 
Writer's cramp, 582 
Wasting palsy, 295 

ZONE, the epileptic, 398 
hysterogenetic, 478 



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THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 

Edited by I. MINIS HAYS, M.D., 
for more than half a century has maintained its position in the front rank of the 
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4 Henry C. Lea's Son & Co.'s Publications — {Dictionaries). 

JJUNGLISON [ROBLEY), M.D., 

"^ Late Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 

MEDICAL LEXICON; A Dictionary op Medical Science: Con- 
taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, 
Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
Jurisprudence and Dentistry. Notices of Climate and of Mineral Waters ; Formulas for 
Officinal, Empirical and Dietetic Preparations ; with the Accentuation and Etymology of 
the Terms, and the French and other Synonymes ; so as to constitute a French as wel] as 
English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- 
ified and Augmented. By Richard J. Dunglison, M.D. In one very large and hand- 
someroyal octavo volume of over 1100 pages. Cloth, $6 50 ; leather, raised bands, $7 50 ; 
half Russia, S8. [Lately Issued.) 
The object of the author from the outset has not been to make the work a mere lexicon or 
dictionary of terms, but to aiford, undereach, a condensedview of its various medical relations, 
and thus to render the work an epitome of the existing condition of medical science. Starting 
with this view, the immense demand which has existed for the work has enabled him, in repeated 
revisions, to augment its completeness and usefulness, until at length it has attained the position 
of a recognized and standard authority wherever the language is spoken. 

Special pains have been taken in the preparation of the present edition to maintain this en- 
viable reputation During the ten years which have elapsed since the Ingt revision, the additions 
to the nomenclature of the medical sciences have been greater than perhaps in any similar period 
of the past, and up to the cime of his death the author labored ast?iduously to incorporate every- 
thing requiring the attention of the student or practiuioner. Since then, the editor has been 
equally industrious, so that the additions to the vocabulary are more numerous than in any pre- 
vious revision. Especial attention has been bestowed on the accentuation, which will be found 
marked on every word. The typigraphical arrangement has been much improved, rendering 
reference much more easy, and every care has been taken with the mechanical execution. The 
work has been printed on new type, small but exceedingly clear, with an enlarged page, so that 
the additions have been incorporated with an increase of but little over a hundred pages, and 
the volume now contains the matter of at least four ordinary octavos. 

aiay safely confirm the Tiope ventured by the editor 
" that the work, which possesses for him a filial as well 
itf an individual interest, will be found worthy a eon- 
Mnuance of the position so lona; accorded to it as a 
standard authoritv." — Cincinmxti Clinic. Jan. 10, 1874. 



A book well known to our readers, and of which 
every American ought to be proud. When the learned 
author of the work passed away, probably all of us 
feared lest the book should not maintain its place 
in the advancing science whose terms it defines. For- 
tunately, Dr. fdchard J. Dunglison, having assisted his 
father in the revision of several editions of the work, 
aad having been, therefore, trained in the methods and 
imbued with the spirit of the book, has been able to 
edit it, not in the patchwork manner so dear to the 
heart of book editors, so repulsive to the taste of intel- 
ligent book readers, but to edit it as a work of the kind 
should be edited— to carry it on steadily, without jar 
or interruption, along the grooves of thought it has 
travelled during its lifetime. To show the magnitude 
of the task which Dr. Dunglison has assumed and car- 
ried through, it is only necessary to stale that more 
than six thousand new subjects have been added in the 
present edition. — Phila. Med. Times, J&ri. 3, 1874. 

About the first book purchased by the medical stu- 
dent is the Medical Dictionary. The lexicon explana- 
tory of technical terms is simply a sine, qua non. In a 
science so extensive, and with such collaterals as medi- 
eiue, it is as much a necessity also to the practising 
physician. To meet the wants of students and most 
physicians, the dictionary must be condensed while 
comprehensive, and practical while perspicacious. Jt 
was because Dunglison's met these indications that it 
became at once the dictionary of general use wherever 
medicine was studied in the English language. In no 
former revision have the alterations and additions been 
80 great. More than six thousand new subjects and terms 
have been added. The chief terms have been set in black 
letter, while Ihe derivatives follow in small caps; an 
arrangement which greatly facilitates reference 



W( 



It has the rare merit that it certainly has no rival 
in the English language for accuracy and extent of 
references. — London Medical f^azettf . 

As a standard work of reference, as one of the best, 
if not the very best, medical dictionary in the Eng- 
lish language, Dunglison's work has been well known 
for about forty years, and needs no words of praise 
on our part to recommend it to the members of the 
medical, and, likewise, of the pharmaceutical pro- 
fession. The latter especially are in need of such a 
work, which gives ready and reliable information 
on thousands of subjects and terms which they are 
liable to encounter in pursuing their daily avoca- 
tions, but with which they cannot be expected to be 
familiar. The work before us fully supplies this 
want. — Am. Journ. of Pharm., Feb. 1874. 

A valuable dictionar.y of the terms employed in 
medicine and the allied sciences, and of the rela- 
tions of the subjects treated under each head. It re- 
flects great credit on its able American author, and 
well deserves the authority and popularity it has 
obcained. — British Med, Journ., Oct. 31, 1874. 

Few works of this class exhibit a grander monu- 
ment of patient research and of scientific lore. The 
extent of the sale of this lexicon is sufficient to tes- 
tify to its usefulness, and to the great service con- 
ferred by Dr. Rjbley Dunglison on the profession, 
and indeed on others, by its issue. — London Lancet , 
May 13. 1S75. 



flOBLYN {RICHARD D.), M.D. 

^A DICTIONARY OF THE TERMS USED IN MEDICINE -AND 

THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hays, 
M. D., Editor of the "American Journal of the Medical Scieaoes." In one large royal 
12mo. volume of over 500 double-columned pages ; cloth, $1 60 ; leath«r, $2 00 

It is the best book of definitions we have, and ought always to be upon the student's t&hle.— Southern 
Med. and Surg. Journal. 



J^ODWELL {O. F.), F.R.A.S., Sfc. 

A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- 
istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostafcicis, Light, Magnetism, 
Mechanics, Meteorology, Pneumatics, Sound and 5?)taties. Preeeded by an Essay on the 
History of the Physical Sciences. In one handsome octavo volume of 694 pages, with 
many illustrations : cloth, $5. 



Henry C. Lea's Son & Co.'s Publications — (Manuals), 5 

A CENTURY OF AlMERIGAN MEDICINE, 1776-1876. By Doctors E. H. 

-^^ Clarke, H. J. Bigelow, S. D. Gross, T. G. Thomas and J. S. Billings. Inone very hand- 
some 12mo. volume of about 350 pages : cloth, $2 25. 
This work appeared in the pages of the American Journal of the Medical Sciences during the 
year 1876. As a detailed account of the development of medical science in America, by gentle- 
men of the highest authority in their respective departments, the profession will no doubt wel- 
come it in a form adapted for preservation and reference. 



-KTEILL {JOHN), M.D., and OMITH {FRANCIS G.), M.D., 

"^ Prof, of the Institutes of Medicine inthe Univ. of Penna 

AN a:n^alytical compendium of the various 

BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A 
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H 



ARTSRORNE [HENRY], M.D., 

Professor of Hygiene in the University of Pennsylvania. 

A CONSPECTUS OF THE MEDICAL SCIENCES; containing 

Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, 
Surgery and Obstetrics. Second Edition, thoroughly revised and improved. In one lar^e 
royal i2mo. volume of more than 1000 closely printed pages, with 477 illustrations on 
wood. Cloth, $4 25 ; leather, $5 00. 

worthy. If students must have a conspectus, they 

will be wise to procure that of Dr. Hartshorne. 

Detroit Rev. of Med. and Pharm., Aug. 1874. 

The work before us has many redeeming features 
not possessed by others, and is the best we have 



We can say with the strictest truth that it is the 
best work of the kind with which we areacquainted. 
It embodies iaa condensed form all recent contribu- 
tions to practical medicine, and is therefore useful 
to every busy practitioner throughout our country, 
besides being admirably adapted to the use of stu- 
dents of medicine. The book is faithfully and ably 
executed.— CAaWes^on Med. Journ., April, 187.5. 

The work is intended as an aid to the medical 



Dr. Hartshorne exhibits much skill in con- 
densation. It is well adapted to the physician in 
active practice, who can give but limited time to the 
1 familiarizing of himself with the important changes 



student, and as such appears to admirably fulfil its j which have been made since he attended lectures. 
object by itsexcellent arrangement, the full compi- I The manual of physiology has also been improved 



latioaof facts, the perspicuity aud terseness of Ian 
guage, and the clear and instructive illustrations 
in some parts of the work. — American Journ. of 
Pharmacy, Philadelphia, July, 1874. 

The volume will be found useful, not only to stu- 
dents, but to many others who may desire torefresh 
their memories with the smallest possible expendi- 
ture of time.— iV. r. Med. Journal, Sept. 1874. 

The student will find this the most convenient and 
useful book of the kind on which he can lay his 
hand. — Pacific Med. and Surg. Journ., Aug. 1874. 

This is the best book of its kind that we have ever 
examined. It is an honest, accurate, and concis 



and gives the most comprehensive view of the latest 
advances in the science possible in the space devoted 
to the subject. The mechanical execution of the 
book leaves nothing to be wished tor .—Peninsular 
Journal of Medicine, Sept. 1874. 

After carefully looking through this conspectus, 
we are constrained to say that it is the most com- 
plete work, especially in its illustrations, of its kind 
that we have seen. — Cincinnati Lancet, Sept. 1874. 

The favor with which the first edition of this 
Compendium was received, was an evidence of its 
various excellences. The present edition beai-s evi- 
dence of a careful and thorough revision. Dr. Harts- 



compend of medical sciences, as fairly as possible ! home possesses a happy faculty of seizing upon the 
representing their present condition. The changes j salient points of each subject, and of presenting them 

and the additions have been so judicious and tho- j in a concise and yet perspicuous manner. Leaven- 

rough as to render it, so far a» it goes, entirely trust- 1 worth Med. Herald, Oct. 1874 



rUDLOW {J.L.), M.D. 
A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 

Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and 
Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
and greatly extended and enlarged. With -370 illustrations In one handsome royal 
12mo. volume of 816 large pages. Cloth, $3 25 ; leather, $3 75. 
The arrangement of this volume in the form of question and answer renders it especially suit- 
able for the office examination of students, and for those preparing for graduation. 



rpANNER [THOMAS HAWKES), M.D., &;c. 

A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 
NOSIS. Third American from the Second London Edition. Revised and Enlarged by 
TiLBTJRY Fox, M. D., Physicia^n to the Skin Department in University Colleg-e Hospital, 
London, «tc. In one neat volume, small 1 2mo. , of about 375 pages, cloth, $1 50. 
*^* On page 3, it will be seen that this work is offered as a premium for procuring new 
subscribers to the "American Journal op the Medical Sciences." 



6 Henry C. Lea's Son & Co.'s Publications — (Anatomy^. 

pRAY {HENRY), F.R.S., 

>-^ Lecturer on Anatomy at Si. George's Hospital, London. 

ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by 

H. V. Carter, M.D., and Dr. Westmacott. The Dissections jointly by the Author and 
Dr. Carter. With an Introduction on General Anatomy and Development by T 
Holmes, M.A., Surgeon to St George's Hospital. A new American, from the Eighth 
enlarged and improved London edition. To which is added the Second American from the 
latest English Edition of " Landmarks, Medical and Surgical," by Luther Holdkn, 
F.K.C.S., author of " Human Osteology," "AManual of Dissections," etc. In one 
magnificent imperial octavo volume of 983 pages, with 522 large and elaborate engrav- 
ings on wood. Cloth, $6; leather, raised bands, $7; half Russia, $7 50. 
The author has endeavored in this work to cover a more extendearange oisuojectsthan is cus- 
tomary in the ordinary text-books, by giving not only the details necessary for the student, biit 
also the applicationof those detailsin the practice of medicine andsurgery, thusrendering it both 
a guide for the learner, and an admirable work of reference for the active practitioner. The en- 
gravings form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in place of 
fio-iires of reference, with descriptions at th» foot. They thus form a complete and splendid series, 
waich will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to 
refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with 
a thorough treatise on systematic, descriptive and applied Anatomy, the work will be found of 
essential use to all physicians who receive students in their offices, relieving both preceptor and 
pupil of much labor in laying the groundwork of a thorough medical education. 

Since the appearance of the last American Edition, the work has received three revisions at the 
hands of its accomplished editor, Mr. Holmes, who has sedulously introduced whatever has seemed 
requisite to maintain its reputation as a complete and authoritative standard text-book and work 
of reference. Still further to increase its usefulness, there has been appended to it the recent 
work by the distinguished anatomist, Mr. Luther Holden — "Landmarks, Medical and Surgical" 
which gives in a clear, condensed and systematic way, all the information by which the prac- 
titioner can determine from the external surface of the body the position of internal parts. Thus 
complete, the work, it is believed, will furnish all the assistance thatcan berendered by typeand 
illustration in anatomical study. No pains have been spared in the typographical execution of 
the volume, which will be found in all respects superior to former issues. Notwithstanding the 
increase of size, amounting to over 100 pages and 57 illustrations, it will be kept, as heretofore, 
at a price rendering it one of the cheapest works ever oflFered to the American profession. 

The recent work of Mr. Holden, which was no- 
ticed by us on p. 53 of this volume, ha« been added 
as an appendix, so that, altogether, this is the most 
practical and complete anatomical treatise available 
to American students and phy;^ician8. The former 
finds in it the necessary guide in making dissec- 
tions; a very comprehensive chapter on minute 
anatomy ; and about all that can be taught him on 
general and special anatomy; while the latter, in 
its treatment of each region from a surgical point of 
view, and in the valuable addilion of Air. Holden, 
will 'find all that will be essential to him in his 
practice. — New Remedies, Aug 1S78. 

This work is as near perfection as one could pos- 
sibly or reasonably expect any book inteoded as a 
text-book or a genera) reference book on anatomy 
to be. The American publisher deserves the thanks 
of the profession for appending the recent work of 
Mr. Holden, '■-Landmarks, Medical and Surgical,''^ 
which has already been commended as a separate 
book. The latter* work— trenting of topographical 
anatomy— has become an essential to the library of 
every intelligent practitioner. We know of no 
book that can take its place, written as it is by a 
most distinguished anatomist. It would be simply 
a waste of words to say anything further in praise 
of Gray's Anatomy, the text-book in almost every 
medical college in this country, and the daily refer- 
ence book of every practitioner who has occasion 



to consult his books on anatomy. The work is 
simply indispensable, especially this present Amer- 
ican edition. — Va. Med. Monthly, Sept. 1878. 

The addition of the recent work of Mr. Holden, 
as an appendix, renders this the most practical and 
complete treatise available to American students, 
who find in it a comprehensive chapter on minute 
anatomy, about all that can be taught on general 
and special anatomy, while its treatment of each 
region, from a surgical point of view, in the valu- 
able section by Mr. Holden, is all that will be essen- 
tial to them in practice.— OAzo Medical Recorder, 
Aug 1S7S. 

It is difficult to speak in moderate terms of this 
new edition of "Gray." It seems to be as nearly 
perfect as it is possible to make a book devoted to 
aay branch of medical science. The labors of the 
eminent men who have successively revised the 
eight editions through which it has passed, would 
seem to leave nothing for future editors to do. The 
addition of Holden's " Landmarks" will make it as 
indispensable to the practitioner of medicine and 
surgery as it has been heretofore to the student. As 
regards completeness, ease of reference, utility, 
beauty, and cheapness, it has no rival. No stu- 
dent should enter a medical school without it ; no 
physician can afford to have it absent from his 
library.— Si. Louis OUn. Record, Sept. 1878. 



w 



H 



Also for sale separate — 
'OLDEN {LUTHER), F.R.C.S., 

Surgeon to St. Bartholomew's and the Foundling Hospitals. 

LANDMARKS, MEDICAL AND SURGICAL. Second American, 

from the Latest Revised English Edition, with additions by W. W. Keen, M.D., Prof, of 
Artistic Anatomy in the Penna. Academy of the Fine Arts, formerly Lecturer on Anat- 
omy in the Phila. School of Anatomy. In one handsome 12mo. volume, of about 140 
pages. Cloth, $1.00. {Just Ready.) 

EA TE ( CHRISTOPHER), F.R. C.S., 

Teacher of Operative Surgery in University College, London. 

PRACTICAL ANATOMY: A Manual of Dissections. From the 

Second revised and improved London edition. Edited, with additions, by W. W. Keen, 
M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. 
In one handsome royal 12mo. volume of 578 pages, with 247illustration8. Cloth, $3 60 ; 
leather, $4 00. 



Henry C. Lea's Son & Co.'s Publications — (Anatomy). T 

A LLEN (HARRISON), M.D. 

•^-*- Pmfesfior of Physiology in the. Univ. of Pa. 

A SYSTEM OF HUMAN ANATOMY: INCLUDING ITS MEDICAL 

and Surgical Relations. For the Use of Practitioners and Studentsof Medicine. With nn 
IntroductoryChapter on Histology. By E. 0. Shakespeare, M D., Ophthalmologistto the 
Phila. Hosp. In one large and handsome quarto volume, with several hundred original 
illustrations on lithographic plates, and numerous wood-cuts in the text. {Shortly.) 
In this elaborate work, which has been in active preparation for several years, the author has 
Bought to give, not only the details ofdescriptive anatomy in a clear and condensed form, but also 
the practical applications of the science to medicine and surgery. The workthus has claims upon 
the attention of the general practitioner, as well as of thestudent, enabling him not only to re- 
fresh his recollections of the dissecting room, but also to recognize thesignificanee of all varia- 
tions from normal conditions. The marked utility of the object thus sought by the author is 
self-evident, and his long experience and assiduous devotion to its thorough development are a 
sufficient guarantee of the manner in which his aims have been carried out. No pains have been 
spared with the illustrations. Those of normal anatomy are from original dissections, drawn on 
stone by Mr. Hermann Faber, with the name of every part clearly engraved upon the figure, 
after the manner of " Holden" and " Gray, " and in every typographical detail it will be the 
effort of the publishers to render the volume worthy of the very distinguished position which is 
anticipated for it. 

JPILIS [GEORGE VINER) 

-*--^ Emeritus Proftssor of Anatomy in University College, London. 

DEMONSTRATIONS OF ANATOMY; Being a Guide to the Know- 

ledge of the Human Body by Dissection. By George Yiner Ellis, Emeritus Professor 
of Anatomy in University College, London. From the Eighth and Revised Lundon 
Edition. In one very handsome octavo volume of over 700 pages, with 256 illustrations. 
Cloth, $4.25 ; leather, $5.25. {Lately Issued.) 
This work has long been known in England as the leading authority on practical anatomv, 
and the favorite guide in the dissecting-room, as is attested by the numerous editions throuo-h 
which it has passed. In the last revision, which has just appeared in London, the accomplished 
author has sought to bring it on a level with the most recent advances of science by making the 
necessary changes in his account of the microscopic structure of the different organs, as devel- 
oped by the latest researches in textural anatomy. 

Ellis's Demonstrations is the favorite text-book its leadership over the English manuals upon dis- 
of the English student of anatomy. In passing secting.— P/a<a. Med. Times, May 24, 1879. 
throuah eight editions it has been so revised and : 

adapted to the needs of the student tba* it would i -^^ a dissector, or a work to have in hand and 
seem that it had almost reached perfection in this studied while one is engaged in dissecting, we re- 
special line. The descrijtions are clear, and the S'^'^^ ^^ ^^ t^^ very best work extant, which is cer- 
methods of pursuing anatomical investigations are thinly saying a very great deal. As a text-book to 
given with such detail that the book is bonestlv be studied in the dissecting-room, it is superior to 
entitled to its name.— St. Louis Clinical Record, any of the works upon &n-dtomy.—Cinein7iuti Med. 
Jane, 1S79. 1 ^VdW-y, May 2-t, 1879, 

The success of this old manual seems to be as well We most unreservedly recommend it to every 

deserved in the present as in the past volumes. "- -.^.= - ^ ,. . 

The book seems destined to maintain yet for years 



practitioner of medicine who can possibly get it. 
Va. Med. Monthly, June, 1879. 



w 



ILSON [ERASMUS], F.R.S. 

A SYSTEM OF HUMAN ANATOMY, General and SpeciaL Edited 

by W.H.GoBRECHT, M.D, Professor oi General and Surgical Anatomy in the Medical Col- 
lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In 
one large and handsome octavo volume, of over 600 pages ; cloth, $4 ; leather, $5. 

MITH [HENRY H.), M.D., and JJORNER ( WILLIAM E.),M.D., 

Prof .of Surgery in the Univ. ofPenna.,&c. LaXeProf. of Anatomy in the Univ. ofPenna. 

AN ANATOMICAL ATLAS ; Illustrative of the Structure of the 

Human Body. In one volume, large imperial octavo, cloth, with about six hundred and 
fifty beautiful figures. $4 50. 

CHAFER [ED WARD ALBERT), M.D., 

Assistant Profe-ssor of Physiology in Univer.iity College, London. 

A COURSE OF PRACTICAL HISTOLOGY: Being an Introduction to 

the Use of the Microscope. En one handsome royal 12mo. volume of 304 pages with 
numerous illustrations: cloth, $2 00. {Lately Issued.) ' 

HORNER'S SPECIAL ANATOMY AND HISTOL- for their Pass Examination. With engravines on 

OGY. Eighth edition, extensively revised and wood In one handsome royal 12nro volume 

modified In 2 vols. Svo., of over 1000 pages, Cloth. $22.5. 

with 320 wood-cuts : cloth, tfi 00 CLELAND-S DIRECTORY FOR THE DISSECTION 

SHARPEY AND QUAIN'S HUMAN ANATOMY. OF THE HUMAN BODY. In one smaUvolum^ 

Revised, by Joseph Leidt, M.D., Prof ot Anat. royal 12mo. of 182 pages- cloth -$1 '>.5 ' 

BELLAMY-S STUDENT'S GUIDE TO SURGICAL lfJ\Vo^\oLZ'^L'\'^^^^^^^ ':ZV 

ANATOMY: A Text-book for Students preparing , $175. woodcuts, cloth 



S 



S 



Henry C. Lea's Son & Co.'s Fvbi^icatioi^s— (Physiology). 



D 



ALTON [J. C), M.D., 

Professor of Physiology in the Collegeof Physicians and Surgeons, New York,&c. 

A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use 

of students and Practitioners of Medicine. Seventh edition, thoroughly revised and rewrit- 
ten, with about three hundred and sixty illustrations on wood. In one very beautiful 
octavo volume, of about 900 pages. {Nearly Ready.) 

A few notices of the previous edition are appended. 



Prof. Dalton has discusi^ed contiicting theories anu 
conclusions regarding physiological questions with a 
fairness, a fulness, and a conciseness which lend fresh- 
ness and vigor to the entire book. But his discussions 
have been so guarded by a refusal of admission to those 
speculative and theoretical explanations, which at best 
exist in the minds of observers themselves as only pro- 
babilities, that none of his readers need be led into 
grave errors while making them a study .—T/ieJl/edzca/ 
Record, Feb. 19, 1876. 

For clearness and perspicuity, Dalton's Physiology 
commended itself to the student years ago, and was a 
pleasant relief from the verbose productions which it 
supplanted. Physiology has, however, made many ad- 
vances since then— and while the style has been pre- 
served intact, the work in the present edition has been 
brought upfuUyabreastof the times. Thenew chemical 
notation and nomenclature have also been introduced 
into the present edition. Notwithstanding the multi- 



plicity of text-books on physiology, this will lose none 
of its old time popularity. The mechanical execution 
of the work is all that could be desired. — Peninsular 
Journal of Medicine., Dec. 1875. 

This popular text-book on physiology comes to us in 
its sixtheditionwiththeadditionofaboat fifty per cent, 
of new matter, chiefly in the departments of patho- 
logical chemistry and the nervous system, where the 
principal advances have been realized. With so tho- 
rough revision and additions, that keep the work well 
up to the times, its continued popularity may be confi- 
dently predicted, notwithstanding the competition it 
may encounter. The publisher's work is admirably 
done. — St. Louis Med. and Su7-g.Jou7-n.,'Dec.l815. 

The revision of this greatworkhas.broughtitforward 
with the physiological advances of the day, and renders 
it, as it has ever been, the finest work for students ex- 
cant. — N'ashville Journ.of Med. and Surg., Jan. 187 6. 



pARPENTER ( WILLIAM B.), M. D., F. R. S., F.G.S., F.L.S., 

^^ Registrar to University of London, etc. 

PRINCIPLES OF HUMAN PHYSIOLOGY; Edited by HenryPower, 

M.B. Lond., F.R.C.S., Examiner in Natural Sciences, University of Oxford. Anew 
American from the Eighth Prevised and Enlarged English Edition, with Notes and Addi- 
tions, by Erancis G. Smith, M.D., Professor ol thelnstitutescf Medicinein the Univer- 
sity of Pennsylvania, etc. In one very large and handsome octavo volume, of 1083 pages, 
with two plates and 373 engs. on wood. Cloth, $5 60 j leather, $6 50; half Russia, $7. 
have been agreeably surprised to fiod the vol- new a year or two ago, looks now as if it had been a 

received and established fact for years. In this ency- 
clopsedic way it is unrivalled. Here, as it seems to 
us,is thegreatvalue of the book; one is safe in sending 
a student to it for information on almost any given 
subject, perfectly certain of the fulness of information 
it will convey, and well satisfied of the accuracy with 
which it will there be found stated. — London Med, 
Times and Gazette, Feb. 17, 1877. 

The meritsof "Carpenter's Physiology" are so widely 
known and aj/preciated ihat we need only allude briefly 
to the fact that in thelatestedition will be found a com- 
prehensive embodiment of the results of recent physio- 
logical investigation. Care has been taken to preserve 
the practical character of the original work. In fact 
the entire work has been brought up to date, and bears 
evidenceof the amount of labor that has been bestowed 
upon it by its distinguished editor, Mr. Henry Power. 
The American editor has made the latest additions, in 
order fully to cover the time that has elapsed since the 
last English edition.— iV". Y. Med. Jowrna^, Jan. 187 7. 



ume so complete in regard to the structure and func- 
tions of the nervous system in all its relations, a 
subject that, in many respects, is one of the mostdiffi- 
eult of all, in the whole range of physiology, upon 
which to produce a full and satisfactory treatise of 
the class to which the one before us belongs. The 
additions by the American editor give to the work as 
it is a considerable value beyond that of the last 
English edition. In conclusion, we can give our cor- 
dia,l recommendation to the work as it now appears. 
The editors have, with thwr additions to the only 
work on physiology in our language that, in the full- 
est sense of the word, is the production of a philoso- 
pher as well as a physiologist, brought it up as fully 
as could be expected, if not desired, to the standard 
of our knowledge of its subject at the present day. 
It will deservedly maintain the place it has always 
nad in the favor of the medical profession. — Journ. 
of Nervous and Mental Disease, April, 1877. 

Such enormous advances have recently been made in 
our physiological knowledge, that what was perfectly 



POSTER [MICHAEL], M.D., F.R.S., 

X Prof, of Physiology in Cambridge Univ., England. 

TEXT-BOOK OF PHYSIOLOGY. Second American from the Latest 

English Edition. Edited, with Extensive Notes and Additions, by Edward T. Reichert, 
M.D., Late Demonstrator of Experimental Therapeutics in the Univ. of Penna. In one. 
handsome royal 12mo. volume of about 1000 pages, wit*h 260 illustrations. Cloth, $3 25 ; 
leather, $3 75. {Jnst Ready.) 

In the preparation of a second American edition of Mr. Foster's Physiology, the editor has 
endeavored to render it more than ever acceptable to the student as a clenr and comprehensive 
textbook, presenting the science in its latest developments. The original work being an ex- 
position of abstract physiology without any reference to the details of physiological anatomy, 
n seemed desirable to introduce some account of structure, in order to render more intelligi- 
ble to the student the views and theories of the science. This the editor has added,;in°as 
concise a manner as possible; and in aid of this end has freely introduced illustrations' Irom 
recognizad authorities. 



LEHMANK'S MANUAL OF CHEMICAL PHYSIOL- 
OGY. Translated from the German, with Notes 
and Additions, by J. Cheston Morris, M.D. With 
illustrations on wood. In one octavo volume ol 
336 pages. Cloth, $2 25. 



LEHMANN'S PHYSIOLOGICAL CHEMISTRY. Com- 
piete in two large octavo volumes of 1200 pages, 
with 200 illustrations; cloth, $6. 



Henry C. Lea's Son & Co.'s Publications — {Chemistry). 9 

J TTFIELD {JOHN). Ph.D., 

•^-*- Professor of Practical Chemistryto the Pharmacetctical Society of Great Britain, &e. 

CHEMISTRY, GENERAL, MEDICAL AND PHARMACEUTICAL; 

Including theChemistry of the IT. S. Pharmacopoeia. A Manual of the G-eneral Principles 

of the Science, and their Application to Medicine and Pharmacy. Eighth edition, revised 

bv the author. In one handsome royal 12mo. volume of 700 pages, with illustrations. 

Cloth, $2 50 ; leather, $3 00. {Noio Ready.) 

We have repeatedly expressed our favorable ; of chemistry in all the medical colleges in the 

opinion of this -work, and on the appearance of a ; United States. The present edition contains such 

new edition of it, little remains for ns to say, ex- i alterations and additions as seemed necessary for 

cept that we expect this eighth edition to "be as the demonstration of the latest developments of 

indispensable to us as the seventh and previous chemical principles, and the latest applications of 

editions have been. While the general plan and chemistry to pharmacy. It is scarcely necessary 

arrangement have been adhered to, new matter ; for ns to say that it exhibits chemistry in its pre- 

has been added covering the observations made '• sent advanced state. — Cincinnati Medical News, 

since the former edition. The present differs from April, 1S79. 



The popularity which this work has enjoyed 



the preceding one chiefly in these alterations and __ _„_ 

in about ten pages of u.sefnl tables added in the owing tVfhe oVig'ical and' ciear"disposUion"orthe 
appendix. -4m. Journ. of Pharraacy, May, l5/9. , f^cts of the science, the accuracy of the details, and 

A standard work like Attfleld's Chemistry need the omission of much which freights many treatises 
only be mentioned by its name, withont further heavily without briugingcorrespondinginstruction 
comments. The present edition contains such al- to the reader. Dr. Attfield writes for students, and 
terations and additions as seemed necessary for primarily for medical students; he always has an 
the demonstration of the latest developments of eye to the pharmacopoeia and its officinal prepara- 
chemical principles, and the latest applications of tions ; and he is continually putting the matter ia 
chemistry to pharmacy. The author has bestowed the text so that it responds to the questions with 
arduous labor on the revision, and the extent of which each section is provided. Thus the student 
the information thus introduced may be estimated learns easily, and' can always refresh and test his 
from the fact that the index contains three hun- | knowledge. — Med. and Surg. Reporter, K^tHIQ, '19. 
dred new references relating to additional mater- j -^Ve noticed only about two years and a half ago 
M fcj'^'Q^^^'*^*' ^"■''^'^^''" ^''^^ Chemical Gazette,, ^^ publication of the preceding edition, and re- 
May, 1S.'9. , marked upon the exceptionally valuable character 

This very popular and meritorious work has ' of the work. The work now iacludes the whole of 
now reached its eighth edition, which fact speaks the chemistry of the pharmacop(Bia of the United 
in the highest terms in commendation of its excel- '■ States, Great Britain, and ln.A.i&.—New Remedies, 
lence. It has now become the principal text-book May, 1879. 



G 



REENE [WILLIAM H.), 31. D.. 

De-monstrntor of Chewi'stri/ in Med. Dept , Univ. of Penna. 

A MANUAL OF MEDICAL CHEMISTRY. For the Use of Students. 

Based upon Bowman's Medical Chemistry. In one royal 12mo. volume of 312 pages 
With illustrations. Cloth, $1 75. {Now Ready.) 

It is well written, and gives the latest views on I The little work before us is ooe which we think 
vital chemistry, a subject with which most physi- will be studied with pleasure and profit. The de- 
dans are not sufficiently familiar. To those who scriptions, though brief, are clear, and in most cases 
may wish to improve their knowledge in that direc- sufficient for the purpose This book will, in nearly 
tion, we can heartily recommend this work asbeing all cases, meet general approval. — Am. Journ. of 
worthy of a carefulperusal. —PftiZa. Med. and Surg. Phavmacy, April, 18S0. 
Reporter, April 24, ISSO. 



ffLASSEN [ALEXANDER], 

^-^ Professor in the Royal Polytechnic School, Aix-la-Chapelle. 

ELEMENTARY QUANTITATIYE ANALYSTS. Translated with 

notes and additions by Edgar F. S.^i:rT^, Ph.D.. Assist^mt Prof, of Chemistry in the 
Towne Scientific School, Univ. of Penna. In one handsome royal 12tuo. volume, of 324 
pages, with illustrations ; cloth, $2 00. (Lately Issued.) 

It is probably the best manual of an elementary , advancing to the analysis of minerals and such pro- 
nature extant, insomuch as its methods are the best, ducts as are met with in applied chemistry. It is 
It teaches by examples, commencing with single an indispensable book for students in chemistry.— 
determinations, followed by separations, and then Boston Journ. of Chemistry, Oct. 1S7S. 

(lALLOWAY [ROBERT). F.C.S.. 

^^ Prof, of Applied Chemistry in the Royal College of Science for Ireland, etc. 

A MANUAL OF QUALITATIYE ANALYSIS. From the Fifth Lon- 
don Edition. In one neat royal 12nio. volume, with illustrations ; cloth, $2 75. 

T^E3ISEN{IRA), M.D., Ph.D., 

Professor of Che-miatry in the Johns Hopliins University, Baltimore. 

PRINCIPLES OF THEORETICAL CH^:MISTRY, with spenal reference 

to the Constitution of Chemical Compounds. In one handsome royal 12mo. vol. of over 
232 pages: cloth, $1 50. 



BOWMAX'S I]>fTRODUCTIOJf TO PRACTICAL ■ WOHLER AXD FITTIG'S OUTLINES OF OEGAK-IC 
CHEMISTRY, INCLUDING ANALYSIS. Sixth. CHEMISTRY. Translated, with additions, from the 
American, from the Sixth and revised London edi- Eighth German Edition. By Ira Remsex. M D., 
tion. With numerous illustrations. In one neat Uh D., Prof of Chemistry and Physics in Williams 
vol., royal 12mo., cloth, $2 25. College, Mass. In one volume, ro'yal 12mo. of 550 

pp., cloth, $3. 



10 



Henry C. Lea's Son & Co.'s Publications — (Chemistry), 



pOWNES {GEORGE), Ph.D. 

A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 

Practical. Revised and corrected by Henby Watts, B. A., F R.S., author of ''A Diction- 
ary of Chemistry," etc. With a colored plate, and one hundred and seventy-seven illus- 
trations. A new American, from the Twelfth and enlarged London edition. Edited by 
Robert Bridges, M.D. In one large royal 12mo. volume, of over 1000 pages; 

cloth, $2 75 ; leather, $3 25. {Lately Issued.) 

what formidable magnitude with its more than a 
thousand pages, but with less than this no fair repre- 
sentation of chemistry as it now ivscan be given. The 
type is small but very clear, and the sections are very 
lucidly arranged to facilitate study and reference. — 
Mefl and Surg. Reporter, Aug 3, 1878. 

The work is too well known to American stodents 
to need any extended notice; suffice it to say that 
the revi^ion by the English editor has been faithfully 
done, and that Professor Bridges has added some 
fresh and valuable matter, especially in the inor- 
ganic chemistry. The book has always been a fa- 
vorite in this counrry, and in its new shape bids 
fair to retain all its former prestige. — Boston Jour, 
of Ohemisitry , Aug. 1878. 

It will be entirely annecessary for us to make any 
remarks relating to the general character of Fownes' 
Manual. For over twenty years it has held the fore- 
most place as a text-book, and the elaborate and 
thorough revisions which have been made from time 
to time leave little chance for any wide a wake rival to 
step before it. — Canadian Pharm. Jov.r., Aug. 1878. 

As a manual of chemistry it is without a superior 
in the language. — Md. Med. Jour., Aug. 1878. 



This work, inorganic and organic, is complete in 
one convenient volume. In its earliest editions it 
was fully up to the latest advancements and theo- 
ries of that time. In its present form, it presents, 
in a remarkably convenient and satisfactory man- 
n-n-, the principles and leading facts of thechemistry 
of to-day. Concerning the manner in which the 
various subjects are treated, much de.serves to be 
said, and mostly, too, in praise of the book. Are- 
view of such a work as Fownes'' s Chemistry within 
the limits of a book-notice for a medical weekly is 
simply out of the question. — Oincinnati Lancet and 
Clinic, Dec. 1-1,1878. 

When we state that, in our opinion, the present 
edition sustains in every respect the high reputation 
which its predecessor's have acquired and eujoyed, 
we express therewith our full belief in its intrinsic 
value as a text-book and work of reference. — Am. 
Journ. of Pharm., Aug. 1878. 

The conscientious care which has been bestowed 
upon it by the American and English editors renders 
it still, perhaps, the best book for the student and the 
practitioner who would keep alive the acquisitions 
of his student days. It has, indeed, reached a some- 



B 



LOXAM iC.L.), 

Professor of Chemistry in King'' s College, London. 

CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- 

don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illus- 
trations. Cloth, $4 00 ; leather, $5 00. 



We have in this work a completeand most excel- 
lent text-book for the use of schools, and can heart- 
ily recommend it as such. — Boston Med. and Surg. 
Journ., May 28, 1874. 

The aboveis the title of a work which we can most 
conscientiously recommend tostndeuts of chemis- 
try. It is as easy as a work on chemistry could be 
made, at the same time that it presents a full account 
of thatscienee as it now stands. We have spoken 
of the work as admirably adapted to the wants of 
students; it is quite as well suited to the require- 
ments of practitioners who wish to review their 
chemistry, or have occasion to refresh their memo- 
ries on any point relating to it. In a word, it is a 
book to be read by all who wish to know what is 
thechemistry of the presentday. — American Prac- 
titioner, Nov. 1873. 



It would be difficult for a practical chemist and 
teacher to find any material fault with this most ad- 
mirable treatise. The author has given us almost a 
cyclopsedia within the limits of aconVenient volume, 
and has done so without penning rbe useless para- 
graphs too commonly making up a great part of the 
bulk of many cumbrous works. The progressive 
scientist is not disappointed when he looks for tba 
record of new and valuable processes and discover- 
ies, while the cautions conservative does not find its 
pages monopolized by uncertain theories and specu- 
lations. A peculiar point of excellence is the crys- 
tallized form of expression in which great truths are 
expressed in very short paragraphs. Oneissnrprised 
a t the brief space allotted to an important topic, and 
yet, after reading it, he feels that little, if any more 
should have been said. Altogether, it is seldom yoa 
see a text-book so nearly faultless. — Cincinnati 
Lancet, Nov. 187a. 



Q 



LOWES (FRANK), D.Sc, London. 

Senior Science- T^fastKr atthe High School , Newcastle-un der-Lyme, etc. 

AN ELEMENTARY TREATISE ON PRACTIC 4L CHEMISTRY 

AND QUALITATIVE TNORGAWIC ANALYSIS. Specially adapted for Use in the 
Lal^oratories of Schools and Colleges and by Beginners. Second American from the 
Third and Revised English Edition. In one very handsome royal 12mo. volume of 
372 pages, with 47 illustrations. Cloth, $2 60. (just Ready.) 



This is a valuable work for those about to com- 
mence chemistry, the more so as by its use they are 
.«imulianeously acquainted with the manipulation 
of chemical analysis, a method which is the most 
valuable to impart a thorough knowledgeof chemis- 
try. It is a very good little book, and will make 
for itsplf manT warm friends and supporters. It 
treats the subject well and the tabl-^s are very clear 
and valuable. — St. Louis Med. and Surg. Journ., 
Mar. ISSl. 

This work is not only well adapted for use as a 
text- book in medical colleges, but is also one of the 
best that a practitioner can have for convenient re- 



ference and instruction in his library. As a rule, 
.•such volumes are too technical and abstruse for 
study without some didactic aid, but the volume 
piesented is easy of compiehension, and will be of 
great value to college studants and busy prrictitioa- 
ers.— A^. 7. Am. Med. Bi- Weekly, April 9, 1881. 

The tables particularly demand praise, for they 
are admirably formed, both for convenience of re- 
ference and folness of information. In short, we 
do not remember to have met with a book tvhich 
could better serve the studf^nt as a guide to the sys- 
tematic studv of inorganic chemistry. — Louisville 
Med. News, March 12, 1881. 



KNAPP'S TECHNOLOGY; or Chemistry Applied to 

the Arts and to Manufactures. With American 
additions by Prof. Walter R. Johnson. In two 



very handsome octavo volumes, with 500 wood 
engravings, cloth, $6 00. 



Henry C. Lea's Son & Co.'s Publications — (Phar.^ Mat. 3Ied., etc.). 1 1 



JJOFFMAN [FRED.), Ph.D. and, pO WER {FRED. B.), Ph.D., 

Prof, of Anat. Okem. in Phil Coll. of Pharmacy. 

MANUAL OF CHEMICAL AXALYSIS, as Applied to the ExaMii- 

nation of Medical Chemicals and their Preparations. Being a Guide for the Determi- 
nation of their Identity and Quality, and for the Detection of Impurities and Adultera- 
tions. For the Use of Pharmacists, Physicians, Druggists and Manufacturing C Anists, 
and Pharmaceutical and Medical Studer.ts. Third edition, entirely rewritten ai.TT much 
enlarged. In one very handsome octavo volume, fully illustrated. {Preparing.) 

pARRISH [EDWARD), 

Late Professor of Materia Mediea in the Philadelphia College of Pharmacy . 

A TREATISE ON PHARMACY. Designed as a Text-Book for the 

Student, and as a Guide for the Physician and Pharmaceutist. With many Formulse an i 
Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wiegand. In one 
handsome octavo volume of 977 pages, with 280 illustrations ; cloth, %b 60 ; leather, $6 50; 
half Russia, $7 

Of Br. Parrish'!^ great work on pharmacy it only ^ Usher. It will conveysomeideaoftheliberality which 
remains to be said that the editor has accomplished ' has been bestowed upon its production when we men- 
his work so well as to maintain, in this fo art h edi- r/ion that there are no less than 2S0 carefully executed 
tion, the high standard of excellence which it bad 111 ustrations. In conclusion, we heartily recomrnend 
attainedin previous editions, under the editorship of the work, not only to pharmacists, but also to iL e 
its accomplished author. This has not been accom | multitude of medical practitioners who are obliged 



plished without much labor, and many additions and 
imorovements, involving change;^ in the arrange- 
mentof the several parts of the work, and the addi- 
tion of much new matter. With the modifications 
thus effectedit constitutes, as now presented, a com- 
pendium of the science and art indispensable to the 
pharmacist, and of the utmost value to every 
practitioner of medicine desirous of familiarizing 
himself with the pharmaceutical preparation of the 
articles which he prescribes for hispatients. — Chi- 
cago Med. J'owv-n., July, 1874. 

The work is eminently practical, and has the rare the public with all the mature experience of its au- 
merit of being readable and interesting, while it pre- thor, and perhaps none the worse for a dash of new 
serves astrictly scientificcharacter The whole work blood.— iond. Pharm. Journal, Oct. 17, 1874. 
reflects the greatest credit on author, editor, and pub- 



of 
to compound their own medicines. It will ever hold 
an honored place on our own book.shelves. — Dublin 
Med. Press and Circular, Aug. 12, 1S74. 

Perhaps one, if not the most important book upon 
pharmacy which has appeared in the English lan- 
guage has emanated from the transatlantic press. 
"Parrish"s Pharmacy" is a well-known work on this 
side of the water, and the fact shows us that a really 
useful work neverbecomes merely local in its fame. 
Thanks to the judicious editing of Mr. Wiegand, the 
posthumous edition of "Parrish" has been saved 'o 



QRIFFITH {ROBERT E.), M.D. 

A UNIVERSAL FORMULARY, Containing the Methods of Prepar- 

ing and AdministeringOflicinal and other Medicines. The whole adapted to Physiciai s and 
Pharmaceutists. Third edition, thoroughly revised, with numerous additions, b^ John M. 
Maisch, Professor of Materia Medicain the Philadelphia College of Pharmacy. In onelaro-e 
and handsome octavo volume of abmt 800 pages. Cloth, S4 50 ; leather, $5 50. ° 

A more complete forraularythan itis in its pres j mitted to memory by every student of medicine 
ent form the pharmacist or physician could hardly j As a help to physicians it will be found invnluHble 
desire. To the first some such work is indispeusa j and doubtless will make its wav into libraries no- 
ble, and it ishardlyless essential to the practitionei ; already supplied with a standard work of the kind . 
who compounds his own medicines. Much of what {—TheAmerican Practitioner jliOui&ville July '74* 
is contained in the introduction ought to be com- I > i^ • 



F 



^ARQUHARSON [ROBERT), M.D. , 

Lecturer nn Materia Mediea at St. Mary's Hospital Medical School. 

A GUIDE TO THERAPEUTICS AND MATERIA MEDICA. Se- 

cf^nd American edition, revised by the Author. Enlarged and adapted to the U. S. 
Pharmacopoeia. By Frank WooDBURy, M.D. In one neat royal 12mo. volume of 498 
pages : cloth, $2.25. {Lately Issued.) 

The appearance of a new edition of this conve- j copious notes hare beenintrodnced, embodying the 

revision of the Pharmacopoeia, together wi h 



nient and handy book in less than two years may 
certainly be taken as an indication of its useful 
ness. Its convenient arrangement, and its terse 



latf 

the antid'tes to the more prominent poisons, and 

such of the newer remedial aeent.s as seemed neces- 



ness, and, at the same time, completeness of the sary co the completeness of the work. Tables of 



information given, make it a handy book nf refer- 
ence. — Am,. Joiirn of Pharraacy, June 1879. 

This work contains in moderate compass such 
well-digested facts concerning the physiolog''>al 
and therapeutical action of remedies as are reason- 
ibly established up to the present time. By a con- 



weights and mea.«ures, and a good alphabetical in- 
dex end the ^olnrnB.—Drv ggists' Circular and 
Chemical Gazette, June, 1S79. 

It is a pleasure to think that the rapidity with 
which a second edition is demanded may be taken 
as an indication that the sense of appreciation of the 



venient arrangement the correspondirg effects of value of reliable information regarding the use of 
each article in health and disease are presented in remedies i~ not entirely overwhelmed in the cultiva- 
parallel columns, not only rendering reference tion of pathologicalstudiee, characferisticof the pre- 
easier but also impressing the facts more strongly sent day. This work certainly merits the success it 
o'lon the mind of the reader. The book has been ^ has so quickly achieved. — New Remedies, July, '79. 
adapted to the wants of the American student, and i 



CHRISTISON'S DISPENSATORY. With copious ad- 
ditions, and 213 large wood engravings By R 
Ei+LKSFiET.D Grifpith, M,D. Ons vol. 8vo., pp. 
1000 cloth, $4 00. 



CARPENTER'S PRIZE ESSAY ON THE USE OF 
Alcohoijc Liquors in Health and Disease. New 
edition, with a Preface by D. F. Condie. M D., and 
explanationsof scientifipwords. In oneneat i2mo. 
volume, pp. 178, cloth, 60 cents. 



12 Henry C. Lea's Son & Co.'s Publications — (3Iat. Med. and Therap.), 



CfTILLE {ALFRED), M.D., LL.D., and IfAISCH {JOHN M.) 

1^ Prof, of Theory and Practice of Medicine JJ-L Prof, of Mat. Med. am. 



\,Ph.D., 

id Bot. in Phila. 
and of Clinical Med. in Univ. of Pa. Coll. Phnrm.ncy.Se.ey.tothe Awierican 

Pharmaceutical Association. 

THE NATIONAL DISPENSATORY: Contaiuing the Natural History, 

Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in 
the Pharmacopceias of the United St.ttes, Great Britain and Germany, with numer- 
ous references to the French Codex. Second edition, thoroughly revised, with numerous 
additions. In one very handsome octavo volume of 1692 pages, with 239 illustrations. 
Extra cloth, $6 75 ; leather, raised bands, $7 50; half Russia, raised bands and open 
back, $8 25. (Now Ready.) 

Preface to the Second Edition. 

The demand which hag exhausted in a few months an unusually large edition of the National 
Dispensatory is doubly gratifying to the authors, as showing that they were correct in thinking 
that the want of such a work was felt by the medical and pharmaceutical professions, and that 
their efforts to supply that want have been acceptable. This appreciation of their labors has 
stimulated them in the revision to render the volume more worthy of the very marked favor 
with which it has been received. The first edition of a work of fuch magnitude must necessarily 
be more or less imperfect ; and though but little that is new and important has been brought 
to light in the short interval since its publication, yet the length of time during which it was 
passing through the press rendered the earlier portions more in arrears than the la'er. The 
opportunity for a revision has enabled the authors to scrutinize the work as a whole, and to 
introduce alterations and additions wherever there has seemed to be occasion for improve- 
ment or greater completeness. The principal changes to be noted are the introduction of seve- 
ral drugs under separate headings, and of a large number of drugs, chemicals and pharma- 
ceutical preparations classified as allied drugs and preparations under the heading of more 
important or better known articles : these additions comprise in part nearly the entire German 
Pharmacopoeia and numerous articles from the French Codex. All new investigations which 
came to the authors' notice up to the time of publicsition have received due consideration. 

The series of illustrations has undergone a corresponding thorough revision. A number have 
been added, and still more have been substituted for such as were deemed less satisfactory. 

The new matter embraced in the text is equal to nearly one hundred pages of the first edition. 
•Considerable as are these changes as a whole, they have been accommodated by an enlargement 
of the page without increasing unduly the size of the volume. 

While numerous additions have been made to the sections which relate to the physiological 
action of medicines and their use in the treatment of disease, great care has been taken to 
make them a.s concise as was possible without rendering them incomplete or obscure. The 
doses have been expressed in the terms both of troy weight and of the metrical system, for the 
purpose of making those who employ the Dispensatory familiar with the latter, and paving the 
way for its introduction into general use. 

The Therapeutical Index has been extended by about 2250 new references, making the total 
number in the present edition about 6000. 

The articles there enumerated as remedies for particular diseases are not only those which, 
in the authors' opinion, are curative, or even beneficial, but those also which have at anytime 
been employed on the ground of popular belief or professional authority. It is often of as 
much consequence to be acquainted with the worthlessness of certain medicines or with the 
narrow limits of their power, as to know the we^l attested virtues of others and the conditions 
under which they are displayed. An additional value possersed by such an Index is, that; it 
contains the elements of a natural classification of medicines, founded upon an analysis of the 
results of experience, which is the only safe guide in the treatment of disease. 

This evidence of success, seldom paralleled, | keep the ■^ork up to the time. — New Remedies, "Nov, 
shows clearly how well the authors have met the | 1879. 



existing needs of the pharmaceutical acd medical 
professions. Gratifying as it must be to them, they 
have embraced the opportunity offered for a thor- 
ough revision of the whole work, striving, to em- 
brace within it all that might have been omitted in 
the former edition, aad all that has newly appeared 
of sufficient importance during the time of its col- 
laboration, and the short interval elapsed since the 
previous publication. After having gone carefully 
through the volume we must admit that the authors 
have labored faithfully, and with success, in main- 
taining the high character of their work as a com- 
pendium meeting the requirements of the day, to 
which one can safely turn in quest of the latest in- 
formation concerning everything worthy of notice in 
connection with Pharmacy, Materia Medica, and 
Therapeutics.— 4m. Jour, of Pharmacy, Nov. 1879. 
It is with great pleasure that we announce to our 
readers the appearance of a second edition of the 
National Dispensatory. The total exhaustion of the 
first edition in the short space of six months, is a 
sufficient testimony to the value placed upon the 
work by the profession. It appears that the rapid 
sale of the first edition must have induced both the 
editors and the publisher to make preparations for 
a new edition immediately after the first had been 
issued, for we find a large amount of new matter 
added and a good deal of the previous text altered 
and improved, which proves that the authors do not 
intend to let the grass grow under their feet, but to 



This is a great work by two of the ablest writers on 
materia medica in America The authors have pro- 
duced a work which, for accuracy and comprehensive- 
ness, is unsurpassed by any work on the subject. There 
is no book in the English language which contains so 
much valuable information on the various articles of 
the materia medica. The work has cost the authors 
years of laborious study, but they have succeeded in 
producing a dispensatory which is not only national, 
but will be a lasting memorial of the learning and 
ability of the authors who produced it. — Ediriburgh 
Medical Journal, Nov. 1879. 

It is by far more international or universal than 
any other book of the kind in our language, and 
more comprehensive in every sense. — Pacific Med. 
and Surg. Jou^n., Oct. 1879. 

The National Dispensatory is beyond dispute the 
very best authority. It is throughout complete in 
all the necessary details, clear and lucid in its ex- 
planations, and replete with references to the most 
recent writings, where further particulars can be 
obtained, if desired. Its value is greatly enhanced 
by the extensive indices — a general index of materia 
medica, etc., and also an index of therapeutics. It 
would be a work of supererogation to say mora about 
this well-known work. No practising physician can 
afford to be without the National Dispensatory.— 
Canada Med. and Surg. Journ., Feb. 1880. 



Henry C. Lea's Son & Co.'s Publications — (Mat. Med,^Therap.^ etc.). 13 

W 



'AISCH {JOHN M.), Phar. I)., 

Prof, of Natn-ia Mnlica avd Botnnu iv fhp PhUa. CJnV, ,f Phnrmnni 

A MANUAL OF ORGANIC MATERIA MEDICA. 



Beinof a Guide 



to Materia. Medica of the Veojetable nnd Animal Kingdoms. For the use of Students, 
Druggists, Pharmacists and Phypici:ins. In one handsome 12mo. volume, with numer- 
ous illustrations on wood. {Preparhig .) 

EXTRACT FROM THE AUTHOr's PREFACE. 

When in 1866 the author was called to the chair of Materia Medica in the institution named 
(the Philadelphia College of Pharrancy), he seriously felt the need of a suitable text book 
which could be used in connection with his lectures, and made preparations for the publication 
of such a work at an early date. To elaborate a system of classification, which should be with- 
out difficulty comprehended and readily applied by those for whom it was intended, was by no 
means an easy task, and the author found occasion, almost every year, to either remodel that 
previously selected, or to make what in his opinion seemed to be desirable improvements. The 
publication of the " National Dispensatory" in a measure supplied the want felt, at least as far 
as a work of reference is conieri;ed. but owing to its local arrangement, it is not adapted to 
systematic instruction. However, its publication rendered a modification of the original plan 
for a treatise on Materia Medica desirable, and it is now presented in a form giving an outline 
of the substance of the lectures and embracing what are considered the essential physical, histo- 
logical, and chemical characters of the organic drug, so as to render the work also a useful and 
reliable guide in business transactions. Regarding the classification, the author is conscious 
of its imperfections, but he believes it to be convenient and capable of practical application. 

In reference to the scope of the work, the main aim has been to embrace all the drugs recog- 
nized by the U. S. Pharmacopoeia, together with the oid. but now unofficinal ones, and such 
others, the use of which has been recently revived or suggested, and which seem to deserve 
attention. The medical properties and doses of the various drugs are merely briefly stated as 
subjects of general important information ; tiie present work is not intended for giving instruc- 
tion in the therapeutic application of drugs. 



OTILLE {ALFRED), M. D., 

Professor of Theory and Practice of Medicine in the University of Penna. 

THERAPEUTICS AND MATERIA MEDICA ; a S.vscematic Treatise 

on the Action and Uses of Medicinal Agents, including their Description and History. 

Fourth edition, revised and enlarged. In two large and handsome 8vo. vols, of a.bout2000 

pages. Cloth, $10; leather, $12; half Russia, $13. 
It is unnecessary to do much more than to an- of the present edition, a whole cyclopasdia of thera- 
peutics. — Chicago Medical Journal, Feb. 1875. 

The rapid exhaustion of three editions and the uni- 
versal favor with which the work has been received 
by the medical profe.s.Tion, are sufficient proof of its 
excelleace as a repertory of practical and useful in- 
formation for the physician. The edition before us 
fully sustains this verdict, as the work has been care- 



nounce the appearance of the fourth edition of this 
well known and excflleut work. — Brit, and For. 
Med.-Ohir. Review, Oct 1875. 

For all who desire a complete work on therapeu- 
tics and materia medica for reference, iu cases in- 
volving medico-legal questions, as well as for in - 
formalionconcerningremedial agents, Dr. Still^'sis 



par ex'^ellence'" the work. Beingout of print, by [ fully revised and in some portions rewritten, bring- 
ing it up to the present time by the admission of 
chloral and crotonchloral. nitrite of amyl, bichlo- 
ride of methylene, methylic ether, lithium com- 
pouuds, gelseminum, and other remedies. — Am. 
Journ. of Pharraacy , Feb. 1S75. 

We can hardly admit that it has a rival in the 
multitade of its citations and the fulness of its Re- 
search into clinical histories, and we must assign it 
a place in the physician's library; not, indeed, as 
fully representing the present state of knowledge 



theexhaustion of former editions, the autlior has laid 
the profession under renewed obligations, by the 
careful revision, importantadditions, and timely re- 
issuing a work not exactly supplemented by any 
other in the English language, if in any langnage. 
The mechanical execution handsomely sustains the 
well-known skill and good taste of the publisher. — 
St, Louis Med. and Surg. Journal, Dec. 1874. 

From the publication of the first edition "Still^'s 
Therapeutics" has been one of the classics; its ab- 



sence from our libraries would create a vacuum | pharmacodynamics, but as byfar the most complete 
which could be filled by no other work in the Ian- treatise upon the clinical and practical side of the 
guage, audits presence supplies, in the two volumes i question. — Boston Med. and Surg. Journal, ^^ov. 5, 

I 1S74. 



flORNIL (F.), AND 

^ Prof, in the Faculty of Med , Paris 



PANVIER {L.), 

-*- ^ Prof in the College of France. 

MANUAL OF PATHOLOGICAL HISTOLOGY. Translated, with 

Notes and Additions, by E. 0. Shakespeare, M.D., Pathologist and Ophthalmic Surgeon 
to Philada. Hospital, Lecturer on Refraction and Operative Ophthalmic Surgery in TIniv. 
of Penna., and by Henry C. Stmes. M D., Demonstratrr of Pathological Histology in 
the Univ. of Pa. In one very handsome octavo volume of over 700 pages, with over 
350 illustrations. Cloth, $5 50; leather, $6 50; half Russia, $7. (J^tst Ready.) 



We have nohesit^tionin cordially recommending 
the English translntion of Coruil & Eanvier's "Pa- 
thological Histology" as the best work of the kind 
in any language, and as giving to its readers a 
trustworthy gui'de in obtaining a broad and solid 
basis for the appreciation of the practical bearings 
of pathological anatomy. — Am. Journ. of Med. 
SHences, AttII, 1880. 

This important work, in it« American dress, is a 
welcome. oB'ering to all students of the subjects 
which it treats. The gr^at mass of material is 
arranged naturally and comprehensively. The 
cliboification of tumors is clear and full, so far as 



the subject idmits of definition, and this one chap- 
ter is worth the price of the book. The illustra- 
tions are copious and well chosen. Without the 
slightest he'^itation, the translators deserve honest 
thanks for placing this indispensable work in the 
hands of American students.— P/it7a. Med. Times, 
April 24, "18^0 

This i-olume we cordially commend to the profes- 
sion. It will prove a valuable, almost necessary^ 
addition to the libraries of students who are to be 
physiciHus, and to the libraries of students who ar© 
physicians.— ^//ierican Practitioner, June, ISSO. 



14 Henry C. Lea's Son & Co.'s F jjbi,ig atiq-ss— (Pathology, etc.), 
JPENWICK {SAMUEL), M.D., 

-*- Assistant Physician to the London Hospital, 

THE STUDENT'S GIJIDE TO MEDICAL DIAGNOSIS. From the 

Third Revised and Enlarged English Edition. With eighty-four illustrations on wood. 
In one very handsome volume, royal 12mo. , cloth, $2 25. {Lately Issued.) 

QEEEN (T. HENRY), M.D., 

^-^ Lecturer on Pathology and Morbid Anatomy at Oharing-Oross HospUal Medica I School, etc. 

PATHOLOGY AND MORBID ANATOMY. Fourth American, from 

the Fifth Enlarged and Revised English Edition. In one very handsome octavo volume 
of about 350 pages, with 138 fine engravings; cloth, $2 25. (Just Ready.) 
Extract from the Author's Preface. 
In preparing the fifth edition of my Text-book on Pathology and Morbid Anatomy, I have 
again added much new matter, with the object of making the work a more complete guide for 
the student. All the chapters have been carefully revised, some alterations have been made in 
the arrangement of the work, and an addition has been made to the number of wood-cuts. The 
new wood cuts, as in previous editions, have been drawn by Mr. Collings from my own micro- 
scopical preparations. 

We have long considered this the best guide yet 
presented to the student for the identification of va- 
rious morbid tissues. We have found it more satis- 



factory than any other. The present edition has 



been thoroughly revised, and much new matter 
has been added. To the physician as a guide in 
diagnosis, we recommend this \olnme.— Physician 
and Surgeon, May, 1S81. 



A 



f^RISTOWE [JOHN SYER), M.D., F.R.C.F., 

Physician and Joint Lecturer on Medicine, St. Thomas'' s Hospital. 

TREATISE ON THE PRACTICE OF MEDICINE. Second 

American edition, revised by the Author. Edited, with Additions, by James H. Hutch- 
inson, M.D., Physician to the Penna. Hospital. In one handsome octavo volume of 
nearly 1200 pnges. With illustrations. Cloth, $5 00 j leather, $6 00; half Russia, 
$6 50. {Now Ready.) 
The second edition of this excellent work, lilse the 

fir.«t, has received the benefit of Dr. Hutchinson's 

annotations, by which the phases of disease which 

are peculiar to this country are indicated, and thus 

a treatise which was intended for British practi- 
tioners and students is made more practically useful 

on this side of the water. We see no reason to 

modify the high opinion previously expressed with 

regard to Dr. Bristowe's work, except by ad<1ing 

our appreciation of the careful labi^rs of the author 

in following the lateral growth of medical science. 

— Boston Medical and SurgiealJournal, February, 

3880. 

What we said of the first edition, we can, with 

increased emphasis, repeat concerning this: "Every 

page is characterized by the utterances of a thought- 
ful man. What has been said, has been well said, 

and the book is a fair reflex of all that is certainly 

kni^wn on the subjects considered." — Ohio Med. 

Recorder, Jan. 7, 1880. 



The views of the author are expressed with preci- 
sion and sufficient promptness to impress the student 
with the weight of his authority ; and should the 
medical professor differ on any subject from his doc- 
trine, he will need to find strong arguments to carry 
his class to the opposite conclusion. — N. 0. Med. and 
Surg.Journ, Feb. 1880. 

The reader will find every conceivable subjeot 
connected with the practice of medicine ably pre- 
sented, in a style at once clear, interesting, and con- 
cise. The additions mide by Dr. Hntchinson are 
appropriate and practical, and greatly add to its 
u.sefulness to American readers. — Buffalo Med. and 
Surg. Journ., March, 1880. 

We regard it as an excellent work for students and 
for practitioners. It is clearly written, the author's 
.'■tyle is attractive, and it is especially to be com- 
mended forits excellent exposition of the pathol >%j 
and clinical phenomena of disease. — St. Louis Clin. 
Record, Feb. 1880. 



fJABERSHON [S. 0.) M.D. 

J--^ Senior Physician to, and late Lecturer on the Principles and Practice of Medicine at, Guy''8 

Hospital, etc. 

ON THE DISEASES OF THE ABDOMEN, COMPRISING THOSE 

of the Stomach, and other parts of the Alimentary Canal, (Esophagus, Caecum, Intes- 
tines and Peritoneum. Second American, from the Third enlarged and revised Eng- 
lish edition. With illustrations. In one handsome octavo volume of over 500 pages. 
Cloth, $3 50. {Lately Issued.) 



This valuable treatise on diseases of the stomach 

and abdomen has been ont of print for several years, 

and is therefore not so well known to the profession 

as it deserves to be. It will be found a cyclopaedia 

of information, systematically arranged, on all dis- 

. eases of the alimentary tract, from the mo'ith to the 

rectum. A fair proportion of each chapter is devoted 

to symptoms, pathology, and therapeutics. The 

(present edition is fuller than former ones in many 

r.particulars, and has been thoroughly revised and 



amended by the author. Several new chapters have 
been added, bringing the work fully up to the times, 
and making it a volume of interest to the practi- 
tioner in every field of medicine and surgery. Per- 
verted nutrition is in some form associated with all 
diseases we have to combat, and we need all the 
light that can he obtained on a subject so broad and 
general. Dr Habershon's work is one that every 
practitioner should read and study for himself.— 
N. Y. Med. Journ., April, 1879. 



vOLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. 
Translated, with Notes and Additions, by Joseph 
Leiut, M. D. In one volume, very large imperial 
quarto, with 320 copper-plate figures, plain and 
colored, cloth. $4 00. 

'LA. ROCHE ON YELLOW FEVER. considered in its 
Historical, Pathological, Etiological and Thera- 
peutical Relations. In two large and handsome 
ofltavo volnmfip of nearly I.'500 pp .cloth $7 00. 

STOKES' LECTURES ON FEVER. Edited by John 
WrijJAM MooRK,M.D., Assistant Physician to the 
Cork Street Fev^r Hospital. In one neat 8vo 
volume cloth, $2 00. 



PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION: its Disorders and their Treatment. 
From the Second London edition. In one hand- 
some volume, small octavo, cloth, $2 00. 

HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol. 8vo., pp. •'iOO, cloth. 11.9 .'50 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With Additions by D. F. Condib, 
M D. 1 vol. 8vo., pp.600, cloth. ^2.50. 

TODD'SCLINIGALLECTURESON CERTAIN ACUTE 
Di.sBASES. In one neat octavo volume, of 320 pp. 
cloth. $2 60. 



Hei^ry C. Lea's Son & Co.'s Publications — (Practice of Medicine). 15 



jCfLINT {A USTIN), M,D., 

•*• Professor of the Principles and Practice of UTedieine in Bellevue Med. College, N F. 

A TREATISE ON THE PRINCIPLES AND PRACTICE OF 

MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fifth 
edition, entirely rewritten and much improved. In one large and closely printed octiivo 
volume of 1153 pp. Cloth, $5 50,- leather, $6 50; very handsome half Russia, raised 
bands, $7. {Just Ready.) 



This work has been so loog and favorably known, 
and has obtained so high a position amongst mod- 
ern treatises on medicine, that it is hardly neces- 
sary to do more than announce the pubUcation of 
this fifth edition. All who peruse it mast be struck 
by the extensive research which has been under- 
taken in the revision of this edition, combined with 
much original thought. There is hardly a subject 
which does not receive fresh illustration and discus- 
sion, opening up new lines of inquiry which had not 
beea thought of when the previous edition appeared. 
We cannot cnnclnde this notice without expressing 
our admiration of this volume, which is certaiuly 
one of the standard text-books on medicine, and we 
m%y safely affirm that, taken altogether, it exhibits 
a fuller and wider acquaintance with recent patho- 
logical inquiry than any similar work with which 
we are acquainted, whilst at the same time it shows 
its author to be possessed of the rare faculties of 
clear exposition, thoughtful discrimination, and 
sound judgment. — London Lancet, July 23, 1881. 

Practically, this edition is a new work ; for so 
many additions and changes have been made that 
one well acquainted with previous editions would 
hardly recognize this as an old friend. The size of 
the volume is somewhat increased. An entire new 
section and several new chapters have been added. 
It is universally conceded that no text book upon 
this subject was ever published in this country 
that can at all compare with it. It has long been 
at the very head of American text-book literature, 
and there can be no doubt but that Lt will be many 



years before it yields the place to others. — Nas''^- 
ville Journ. of Med. and Svrg , Feb. 1881. 

"Flint's Practice"' is recognized to be a standard 
treatise of high rank upon the principles and the 
practice of medicine wherever the English language 
is read. The opinions everywhere reveal the man 
of extensive experience, dilisrent study, calm judg- 
ment, and unbiassed criticism. The work thnuld 
be in the hands of every practitioner. — New York 
Med. Rp.eord, Feb. 26, 1881. 

The style aud character of this work are too well 
known to the profession to require an introduction. 
For a number of years thi>! volume has occupied a 
leading p isition as a text-book in the majority of 
medical schools, and the high position accorded to 
it in the past is a guarantee of a hearty welcome in 
this new edition. The book may be said to represent 
the present state of the science of medicine as now 
understood and taught. It is a safe guide to students 
and practitioners of medicine. — Maryland Medical 
I Journal. March 1, 1881. 

i The author has. in this edition, revised and re- 

i written a great nart and made it accord with the 

more advanced ideas which have been developed 

j within the past few years. He is the more fitted to 

I do so, as he is actively engaged in his profession, 

and can make deductions, not from the work of 

' others, but from his own labors. It is a treatise 

which every American physician should have upon 

1 his table, aud which he should consult oa occasions 

! when his leisure permits him to do so. — St. Louis 

i Med and Snrg. Journal, March, 1881. 



F THE SAME AUTHOR. 

CLINICAL MEDICINE; a Systematic Treatise on the Diagnosis 

and Treatment of Diseases. Designed for Students and Practitioners of Medicine. In 
one large and handsome octavo volume of 795 pages; cloth, $4 50 ; leather, $5 50; 
half Russia, $6. {Now Ready.) 

in this country as that of the author of two works 
of great merit on special subjects, and of numerous 
papers, exhibiting much originality and extensive 
research. — The Dublin Joicrnal, Dec. 1879 



The eminent leacher who has written the volume 
under coasi deration h^s recognized the needs of 
the 4.raerican profession, and thp result is all that 
we could wish. The style in which it i' written is 
peculiarly the author's; it is clear and forcible, and 
marked by those characterieties which have ren- 
dered him one of the best writers aud teachers this 
country has ever produced. We have not space for 
so fall a consideration of this remarkable work as 
we would desire. — St. Louis Olin. Record, Oct. 1879. 

It is here that the skill and learning of the great 
clinician are displayed He has given us a store- 
house of medical knowledge, excellent for the stu- 
dent, convenient for the practitioner, the result of a 
long life of the most faithful clinical work, collect- 
ed by an energy as vigilant and systematic as un- 
tiring, and weighed by a judgment no less clear 
than his observation is clo^e.— Archives of Medi- 
cine, Dec. 1879 

To give an adequate and useful con«pectns of the 
extensive field of modern clinical medicine is a task 
of no ordinary difficulty; but to accomplish this 
consistently, wilhbrevity and clearness, t*he difi'^rpnt 
subjects and their several part--* receiving the atten- 
tion which, relatively to their importance, medical 
opinion claims for them, is still more diificult. Tbis 
task we feel bound to say has been executed wifh 
more than partial success by Dr. Flint, whose name 
is already familiar to students of advanced medicine 



There is every reason to believe that this book 
will be well received. The active practitioner is 
frequently in need of some work that will enable 
him to obtain information in the diagnosi-; and 
treatment of cases with comparatively little labor. 
Dr. Flint has the faculty of expressing himself 
clearly, and at the same time so concisely as to 
enable the searcher to traverse the entire ground 
of his search, and at the same time obtain all that 
is essential, without plodding through an intermi- 
nable space. — N. Y. Med. Jour., Nov. 1879 

The great object is to place before the reader the 
latest observa'iOQs and experience in dingnosis and 
treat neat. Such a w )rk is especially valuable to 
students. It is complete in Its special design, and 
yet so condensed, that he can by its aid, keep up 
with the lectures on practice without neglecting 
other branches. It will not escape the notice of the 
practitioner that such a work is most valuable in 
cul'iug points in diagnosis and treatment in the in- 
tervals between the dally rounds of visits, since he 
can in a few minutes refresh his memory, or learn 
the litest advance in the treatment of diseases which 
demand his instant a'tention. — Cincinnati Lancet 
and aiinic, Oct. 25, 1879. 



JOY THE SAME AUTHOR. 

ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED 

TOPICS, In one very handsome royal 12mo. volume. Cloth, $1 38. {Just Issued.) 



DAVIS'S CLINICAL LECTURES ON V.\RIOUS 
IMPORTANT DISEASES; being a collection of the 
Clinical Lectures delivered in the Medical Wards 
of Mercy Hospital, Chicago. Edited by Frank H 
Davts, M.D. Second edition, enlarged. In one 
handsome royal 12aao. volume. Cloth, $1 75. 



STURGES'S INTRODUCTION TO THE STUDY OF 
CLINICAL MEDICINE. Beinga Guide to the In 
vestigation of Disease. In one handsome 12mo. 
volume, cloth, %1 2a. 



16 Henry C. Lea's Son & Co.'s Publications — {Practice of Medicine). 



LL.D., F.S.A. 



H 



f^ICHARDSON [BENJ. W.), M.I)., F.R.S., M.A. 

J-^ Fellou} of the. Royal Gnllege of Pliysiieians, London. 

PREYENTIYE MEDICINE. In one octavo volume of about 500 pages. 

{Shortly .) 

ARTSHORNE {HENRY), M.D., 

Professor of Hygiene in the University of Pennsylvania 

- ESSENTIALS OF THE PRINCIPLES ANB PRACTICE OF MEDI- 

CINE. A handy book for Students and Practitioners Fifth edition, thoroughly re- 
vised and rewritten. With 140 illustrations. In one hiindsome royal 12mo. volume, of 
about 600 pages. {I?i Press.) 
The very great success which has exhausted four large editions of this work shows that the 
author has succeeded in supplying^ a want felt by a large portion of the profession. It has also 
enabled him in successive revisions to perfect the details of his plan, and to render the work 
?till jaore worthy of the favor with which it has been received. In the present edition several 
hundred brief additions have been mnde, a number of new suV-jects have been written upon, 
esipecially in connection with the Pathology of the Nervous System, the illustrations have been 
considerably increased, and a large number of new and carefully selected formulae for the admi- 
1 istration of medicines have been introduced. An account is given, also, in this edition for th^ 
first time, of the method of prescribing according to the metrical system, and a section is added 
Upon Eyesight, its Examination and Correction. In presenting this editioQ, therefore, the pub- 
lishers feel that it is in every way worthy a continuance of the favor hitherto accorded this work. 



tU-OODBURY {FRANK), M.D.. 

' ' Physician to the German Un&pital, Philadelphia, late Chief Assist, to Med. Clinic, Jeff. College 

Hospital, etc. 

A HANDBOOK OF THE PRINCIPLES AND PRACTICE OP 

Medicine ; for the use of Students and Practitioners. In one neat volume, royal 12mo., 
with illustrations, {hi Press.) 



F' 



'OTHERGILL {J. MILNER), M.D. Ediu., M.R.C.P. Lovd., 

Asst. Phys. to the West Lond Hasp. : Asst. Phys-. to the City of Lond. Hosp.,etc. 

THE PRACTITIONER'S HANDBOOK OF TREATMENT; Or, the 

Principles of Therapeutics. Second edition, revised and enlarged. In one very neat 
octavo volume of about 650 pages. Cloth, $4 00; very handsome half Kussia, $5 50. 
{Jicst Ready.) 



The janior members of the profession will find in 
it a work that should not oaly be read, but care- 
fully studied. It will assist rhem in the proper 
selection aud combiaation of tlier ipeufcical ageuis 
best adapted to each case and coudition, and enable 
them to prescribe iotelli^ently and successfnlly. 
To do full justice to a work of this scope aud char- 
acter will be impossible in a review of this kind. 
The book itself must be read to be fully appreciated 
— St. Louis Courier of Mfdicine^ Nov 1880. 

The author merits the thanks of every well-edu- 



cated physician for his eflforts toward rationalizing 
the treatment of diseases upon the scientific basis 
of physiology. Erery chapter, every line, has the 
impress of a master hand, and while the work is 
thoroughly scientific in -^very particular, it presents 
to the thoughtful reader all the charms and beau- 
ties of a well-written novel. No physician can 
well afford to b^ without this valuable work, for its 
oriajinality makes it fill a niche in medical litera- 
ture hitherto vacant. — Nashville Journ. of Med. 
and Stcrg., Oct. 1880. 



PINLAYSON {JAMES), M.D., 

-*- Physician and Lecturer on Clinical Medioine in the Glasgow Western Infirmary , etc. 

CLINICAL DIAGNOSIS; A Handbook for Students and Prac- 

titioners of Medicine. In one handsome 12mo. volume, of 546 pages, with 85 illustra- 
tions. Cloth, $2 63. {Latel-n Issued.) 
The book is an excellent one, clear, concise, conve- | five from preface to the final page, and ought to be 



aiera, practical. It is replete with the very know- 
ledge the student needs when he quits the lecture- 
room aud the laboratory for the ward and sick-room, 
and does not lack in information that will meet the 
wants of experienced and older men. — Phila. Med. 
Times, Jan. 4, 1879. 
This is one of the really useful books. It is attrac- 



gi ven a place ou every office table, becLi use it contains 
in a condensed form all that is valuable in semeiolngy 
and diagnostics to be found in bulkier voluraps, and 
because in its arrangement and complete index, it is 
unusually convenient for quick reference in any 
emergency that may come upon the busy practitioner. 
—N. C. Med. Journ., Jan. 1S79. 



l^A TSON { THOMAS), M.B., ^c. 

LECTURES ON THE PRINCIPLES AND PRACTICE OF 

PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- 
vised and enlarged English edition. Edited, with additions, and several hundred illuetra- 
tionsjby Henry Hartshorne, M.D., Professor of Hygiene in the University of Penn- 
sylvania. In two lar^e and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. 



WILLIAMS'S PULMONARY CONSUMPTION; its 
Nature, Varieties and Treatment. With an An- 
alysis of One Thousand Cases to exemplify its 
duration. In one neat octavo volume of about 
850 pages; cloth, $2.50. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account of the History of its Pre- 
valence in various Coantries Second and ■•evised 
edition. In one neat royal 12mo. volume, cloth, 
$1 25. 



A' ALSHEON THE DISEASESOF THE HEART AND 
GREAT VESSELS. Third American Edition. In 
1 vol. Svo., 420 pp., cloth, $3 00. 

SMITH ON CONSUMPTION ; ITS EARLY AND RE- 
MEDIABLE STAGES. 1 vol. 8vo.. pp. 254. $2 25. 

FULLER ON DISEASES OF THE LUNGS AND AIR- 
PASSAGES. Their Pathology, Physical Diagnosis, 
Symptoms and Treatment. From the Second and 
revised English edition. In oue handsome octavo 
volume of about 500 pages : cloth, $3 50. 



Henry C. Lea's Son & Co.'s Vvb-licatioss— (Practice of 3Iedicine). 17 
JDEYNOLDS {J. RUSSELL). M.I).. 

J-kj Prof, of the Principles a,nd Practice of Medicine in Univ. College, London. 

A SYSTE>[ OF MRDF^'TNE with Notihs and Additions by HtcxryHarts- 
HORNE, M.D.. late Professor of Hygiene in the UBiversity of Penna. In three large and 
handsome octavo volumes, containinor 3052 closely printed double-columned pa.sre?. with 
numerous illustrations. Sold only by suhscription. Price per vol., in cloth. .$.5.00: in 
sheep, $6.00 : half Russia, raised bands, $6.50. Per set in cloth, §15 ; sheep, .SiS ; half 
Russia, $19.50 
Volume I. (jnst ready) contains General Diseases and Diseases of the NERvors System. 
Volume II. (just ref/dy) contains Disea.'^es of Respiratory and Circulatory SYSTE>rs. 
Volume III. {jtist ready) contains Diseases of the Digestive and Blood Glandular 
Systems, of the Urinary Or&ans, of the Female Reproductive System, and of the 
Cutaneous System. 
Reynolds's System of Medicinte, recently completed, has acquired, since the first appearance 
of the first volume, the well-deserved reputation of being the work in which modern Briti.^h 
medicine is presented in its fullest and most practical form. This could scarce be otherwise in 
view of the fact that it is the result of the collaboration of the leading minds of the profession, 
each subject being treated b}' some gentleman who is reorarded as its highest authority — as for 
instance, Diseases of the Bladder by Sir Henry Thompson, Malpositions of the Uterus by 
Graily Hewitt, Insanity by Henry Maudsley, Consumption by J. Hughes Bennet, Dis- 
ease? of the Spine byCflAR-LES Bland Radcliffe, Pericarditis by Francis Sieson. Alcoholism 
by Francis E. x\nstie. Renal Affections by Vv^illiam Roberts. Asthma by Hyde Salter, 
Cerebral Affections by H Charlton Bastian, Gout and Rheumatism by Alfred Baring Gar- 
rod, Constitutional Syphilis by Jonathan Hutchinson. Diseases of the Stomach by Wilson 
Fox, Diseases of the Skin by Balmanno Squire, Affections of the Larynx by Morell Mac- 
kenzie, Diseases of the Rectum by Blizard Curling, Diabetes by Lauder Brunton, Intes- 
tinal Diseases by John Syer Bristowe, Catalepsy and Somnambulism by Tromas King Cham- 
bers, Apoplexy by J. Hughlings Jackson, Angina Pectoris by Professor Gairdner, Emphy- 
sema of the Lungs by Sir William Jenner, etc. etc. All the leading schools in Great Britain 
have contributed their best men in generous rivalry, to build up this monument of medical sci- 
ence. St. Bartholomew's, Guy's. St Thomas's, University College, St. Mary's, in London, while 
the Edinburgh, Glasgow, and Manchester schools are equally well represented, the Army Medical 
School at Netley, the military and naval services, and the public health boards. That a work 
conceived in such a spirit, and carried out under such auspices should prove an indispensable 
treasury of facts and experience, suited to the daily wants of the practitioner, was inevitable, and 
the success which it has enjoyed in England, and the reputation which it has acquired on this 
side of the Atlantic, have sealed it with the approbation of the two pre-eminently practical nations. 
It? large size and high price having kept it beyond the reach of m.-my practitioners in this 
country who desire to possess it, a demand has arisen for an edition at a price which shall ren- 
der it accessible to all. To meet this demand the present edition has been undertaken. The 
five volumes and five thousard pages of the original have, by toe use of a smaller type and double 
columns, been eompres>ed into three volumes of over three thousand pages, clearly and hand- 
somely printed, and offered at a price which renders it one of the cheapest works ever presented 
to the American profession. 

^But not only is the .Americarj edition more convenient and lower priced than the English; 
it is also better and more complete. Some years having elapsed since the appearance of a 
portion of the work, .additions are required to bring up the subjects to the existing condition 
of science. Some diseases, also, which are comparatively unimportant in England, require more 
elaborate treatment to adapt the articles devoted to them to the wants of the Apjerican physi- 
cian ; and there are point? on which the received practice in this country differs from that 
adopted abroad. The supplying of these deficiencies has been undertaken by Henry Harts- 
hurne, M.D.,late Professor of Hj giene in the University of Pennsylvania, who has endeavored 
to render the work fully up to the day. and as useful to the Ameri'^an physician as it has proved 
to be to his English brethren. The number of illustrations has also been largely increased, and 
no effort spared to render the typographical execution unexceptionable in every respect. 

Really too nuich praise can .scarcely be givea to ' .subjects with which he should be familiar. — Gail' 
this noble book. It is a cyclopa3diti of medicine Uarrf'5 2l/e<:i. J'oMrrt., Feb. ISSO. 
written by bome of the best men of Europe. It is ! , . ,. , , -^ •, 

full of useful inrormanon such as one fiuds frequent | ^^^^^ ^^ no medical work which we have m times 
need of in one's d«ilv work A.< a bck of reference ! P^^' "o^'^ frequently and fully consulted when per- 
it is invaluable. It is up with the times. It L? clear ' P'exed by doubts as to treatment, or by having un- 
and concentrated in .-tyle, and it? form is worthy ; ^i^^al or apparently inexplicable symptoms pre- 
of its famous publisher. — ioui&uiZZe Mtd. News. ' sented to us than "Eeynolds' Sysfem of Medicine." 
Jan. 31 1S80. ' Among its contributors are gentlemen who are as 

' ' " I well known by reputation upon this side of the 

"Reynolds' Sysfem of Medicine" is ju'^tly con- Atlantic as in Great Britain, and whose right to 
sidered the most popular work ou the principles and speak with authority upon the subjects about 
practice of medicine in the English language The which they have written, is recognized the world 
coatributors to this work are gentlemen of well- ove*". They have evidently striven to make their 
known reputation on both .-^ides of the Atlantic, es.-ays as practical as possible, and while these are 
Each gentleman has striven to make his part of the suiiiciently full to entitle them to the name of 
work as practical as pos-ible. and the inronnation monographs, they are not loaded down with such 
contained is such as is needed by the busy practi- ^ -tn amount of detail as to render them wearisome 
tioner. — St. Louin Med. and Surg. Journ. ,Ja.u. 'SO. ' to the general reader. In a word, they contain just 

; that kiiid of information which the busy practitioner 
Dr. Hartshorne has made ample additions and frequently finds himself in need of. In order that 
revi.sions, all of which give increa.-ed value to the any deficiencies may be supplied, Ihe publishers 
volume, and render it more useful to the Ameri- have committed the preparation of the book for the 
can practitioner. There is no volume in English press to Dr. Henry Hartshorne, whose judicious 
medical literature more valuable, and every pur- notesdistributed throughout the volume afi'ord abun- 
chaser will, on becoming familiar with it, congrat- dant evidence of the thoroughness of the revision to 
ulate himself on the pos^essiop of this vat^t store- which he has subjected it. — Am. Jour. Med. Sciences, 
house of information, in regard to so many of the Jan. 1S80. 



18 Henry C. Lea's Son & Co.'s Publications — {Nerv. Dis , So.). 



J?ARTHOLO W [ROBERTS], AM., M.D., LL.D. 

•*-' Prof, of Materia Mediea and General Therapeutics in the Jeff. Med. Ooll. of Phila., etc. 

A PRACTICAL TREATISE ON ELECTRICITY IN ITS APPLI- 
CATION TO MEDICINE. In one very handsome 8vo. volume of about 270 pages, 
with 98 illustrations. Cloth, $2 50. {Just ready.) 

EXTRACT FROM THE AUTHOR'S PREFACE. 

I have attempted in the preparation of this work to avoid these errors; to prepare on=i so 
simple in statement that a student without previous acquaintance with the subject, may read- 
ily master the essentials; so complete as to embrace the whole subject of medical electricity, 
and so condensed as to be complete in a moderate compass. I have endeavored to keep con- 
stantly in view the needs of the two classes for whom the work is prepared — students and prac- 
titioners. I have assumed an entire unacquaintance with the elements of the subject as the 
point of departure — for I am addref^sing those who have either failed to acquire this prelimi- 
nary knowledge, or having acquired it, find that after the lapse of years, it has become misty 
and confused. In the accounts of electrical phenomena I have adhered to the modes of expres- 
sion with which the medical electrical text-books have made us familiar. 

This book, then, must be regarded as the exposition of electricity as a remedial agent, made 
by a medical practitioner for the use of medical practitioners. No claim is made on the ground 
of pure science. It is believed, however, that the work makes an adequate presentation of the 
subject, regarding electricity as a remedial agent — as one of the means employed for the treat- 
ment and cure of disease. 



So far as we know, the need of a clear, Pimple, 
untechnical, reliable, concise, and modern treatise 
upon the subject of medical electricity is only sup- 
plied by the volume under consideration. It is not 
too much to say that, if availed of, it will render 
accessible to a vast number of members of the pro- 
fession a therapeutic agent of the greatest value, but 
which has heretofore been practically of no use 
whatever to them. — Maryland Med. Journal, June 
1, 1881. 

We have not yet come across a book that can com- 
pare with this in clearness and simplicity of state- 
ment. We have for a long time needed a text-book 
on medical electricity, condensed and yet complete, 
and this want has been well supplied by the distin- 
guished author. The illustrations are elegant, and 
the book as a whole is a valuable addition to the 
collection of any student or fir&ctWioner. — Buffalo 
Med. and Surg. Journal, June, 1881. 

As a whole, the book must be looked upon as an 
exposition of electricity for remedial purposes, writ- 
ten by a medical practitioner for the use of medical 



practitioners. From this standpoint the work 13 
worthy of the careful study of all who desire to in- 
vestigate this subject for purely practical purposes. 
This work meets a want of very many students and 
medical practitioners. We greatly err if it be not 
gladly welcomed by them. The author, from his 
long experience as a practitioner, is admirably fitted 
to perform the task of writing a work of this kind 
for this special class of men. — Detroit Lancet, June, 
18S1. 

This book is expressive of careful research and a 
nice discrimination in the selection of such mntter 
from that at the author's command as is best adapfed 
for the gnidance and instruction of the physician 
whose interest in electricity is proportionate to its 
practical bearing on diagnosis and treatment. It is 
thorough, it is accurate, it is readable, and above 
all is essentially utilizable, if we may use the word, 
and renders easy of access to the general practitioner 
the modufi operandi of employing this very valu- 
able therapeutic agent. — N. Y. Medical Gaz., June 
11, 1881. 



TUITCHELL [S. WEIR), M.D., 

JjJ, Phys. to Orthop(sdie Hospital and the Infirmary for Dfs. of the Nervous System, Phila. y etc. etc, 

LECTURES ON DISEASES OP THE NERVOUS SYSTEM, 

ESPECIALLY IN WOMEN. In one very handsome 12mo. volume of about 250 pages, 
with five lithographic plates. Cloth, $1 75 [Just Ready.) 
The life-long devotion of the author to the subjects discussed in this volume has rendered it 
eminently desirable that the results of his labors should be embodied for the benefit of tho.--e 
who may experience the difficulties connected with the treatment of this class of disease. 
Many of these lectures are fresh studies of hysterical affections; others treat of the modifica- 
tions his views have undergone in regard to certain forms of treatment, while, throughout the 
whole work, he has been careful to keep in view the practical lessons of his cases. 

It is a i-ecord of a number of very remarkable v ordinarily rich in acute observation and sound in- 
cases, with acute analyses and discussions, clinical, slruction. The reputation of the author is a guar- 
physiological, and therapeutical It is a book to | antee of that, and no reacer will be disappointed. 



It is a book 
which the physician meeting wi'h a new hysterical 
experience, or in doubt whether his new experience 
is hysterical, may well turn with a well-grounded 
hope of finding a parallelism ; it will be a new ex- 
perience, indeed, if no similar one is here recorded 
—Phila. Med. Times, June 4, 1881. 

The name of the author is sufficient guarantee that 
these topics are ably and appreciativ^ly discussed ; 
sufiice it to say that the principles of treatment, both 
hygienic and therapeutic, are clearly indicated. 
The articles being in the form of clinical lectures, 
abound in illustrative cases, and are much easier 
reading than a systematic treatise on the same 
topics. — College and Clinical Record, May 15, l!^81. 

It is needless to say that these lectures are extra- 



Nor can too much be said in praise of the admirab e 
style of his m-dical writings, and each of these lec- 
tures reads with the fiuished grace of a polishpd 
essay. Indeed, the book throughout is so fascinatini? 
a one that it could not fail to be read entire by every 
one who begins its pages. —Phila. Med. and Surg. 
Reporter, May 7, 1881. 

The book throughout is not only intensely enter- 
taining, but it contains a large amount of rarenud 
valuable information. Dr. Mitchell has recorded 
not only the results of his most careful observation, 
but has added to the knowledge of the subjects treat- 
ed by his original investigation and practical study. 
The book is one we can commend to all of our Tend- 
ers.— Maryland Med. Journal, May 1, 1881. 



TJAMILTON {ALLAN MrLANE), M.D., 

-*•-*• Attending Physician at the Hospital for Epileptics and Paralytics, BlackwelV s Island, N. Y., 

and at the Out- Patients'' Department of the New York Hospital. 

NERYOUSDISEASES;THEIR DESCRIPTION AND TREATMENT. 

Second edition, thoroughly revised and rewritten. In one handsome octavo volume of 
about 600 pages, with numerous illustrations. {In Press.) 



Henry C. Lea's Son & Co.'s Publications — (Dis.ofthe SMn,SG,). 19 
MORRIS (MALCOLM), M.D., 

J-'J- Joint Lecturer on Dermatology, St. Mary^s Hospital Med. School. 

SKIN DISEASES, Including their IJefinitions, Symptoms, Diagnosis, 

ProE^nosis, Morbid Anatomy and Treatment. A Manual for Students and Practitioners. 
In one 12mo. volume of over 300 pages. With illustrations. Cloth, $1 75. (Now Ready.) 

-St. Louis Courier of Medicine, April, 



To phyfiicians who would like to know something 
about skin diseases, so that when a patient present!- 
himself for relief they can make a correct diagnosis 
and prescribe a rational treatment, we unhesitatingly 
recommend this little book of Dr. Morris. The affec- 
tions of the skin are described in a terse, Incid man- 
ner, and their several characteristics so plainly set 
forth that diagnosis will be easy. The treatment 
in each case is such as the experience of the most 
eminent dermatolo£;ist8 advise. — Qincinnati Medi- 
cal News, April, 18S0. 

This is emphatically a learner's book ; for we can 
safely say, so far as our judgment goes, that in the 
whole range of medical literature of a like scope, 
there is no book which for clearness of expression, 
and methodical arrangement is better adapted to 
promote a rational conception of dermatology, a 
branch confessedly difficult and perplexing to the 



beginner.' 
1880. 

The author of this manual has evidently a full and 
intimate acquaintance with the literature of derma- 
tology, and with the most recent developments and 
appliances of cutaneous medicine. He has produced 
a plain, practical book, by aid of which, who so 
chooses may triin his eye to the recognition of 
light but significant differences. The descriptions 
are neither too vague nor over-refined ; the divec- 
tions for treatment are clear and succinct. — London 
Brain, April, 1880. 

The author's task has been well done and has pro- 
duced one of the best recent works upon the difficult 
subject of which it treats ; there is no work published 
which gives a better view of the elementary fact's 
and principles of dermatology. — New Orleans Medi' 
cal and SurgicalJournal, April, 1880. 



F 



'OX { T2LBURF), M.D., F.R.G.P., and T. C. FOX, B.A., M.R.G.S., 

Physician to the Department for Skin Diseases, University College Bospiinl. 

EPITOME OF SKIN DISEASES. WITH FORMULiE. For Stu- 

DBNTS AND PRACTITIONERS. Second edition, thoroughly revised and greatly enlarged. In 
one very handsome 12mo. volume of 216 pages. Cloth, $1 38. 

JjyLINT (AUSTIN), M.D., 

■*■ Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. Y. 

A MANUAL OF PERCUSSION AND AUSCULTATION; of the 

Physical Diagno?is of Diseases of the Lungs and Heart, and of Thoracic Aneurism. 

Second edition. In one handsome royal 12mo. volume : cloth, $1 63. (Just Ready.) 

The little work before us has already become a I author has for mi^ny years given, in connection with 

standard one, and has become extensively adopted | practical instruction in auscultation and percussion, 

as a- text-book. There is certainly none better. It j to private classes, composed of medical students and 

contains the substance of the le.«sons which the | practitioners. — Cincinnati Med. News, Feb. 1880. 



or THE SAME AUTHOR. 

PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- 
ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT 
MENT AND PHYSICAL DIAGNOSIS; in a series of Clinical Studies. By ArsTiH 
Flint, M.D., Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med. 
College, New York. In one handsome octavo volume : $3 50. 



B 



T>T THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 

AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged 
edition . In one octavo volume of 550 pages, with a plate, cloth, $4. 

■DT THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- 
TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume 
of 595 pages, cloth, $4 50. 

ROWN (LENNOX), F.R.G.S. Ed., 

Senior Surgeon to the Central London Throat and Ear Hospital, etc. 

THE THROAT AND ITS DISEASES. Second American, from the 

Second English Edition, thoroughly revised. With one hundred Typical Illustrntions in 
colors, and fifty wood engravings, designed and executed by the author. In one very 
handsome imperial octavo volume of over 350 pages. {Preparing. ) 

^EILER {CARL), M.D., 

A^ Lecturer on Laryngoscopy at the Univ. of Penna., Chief of the Throat Dispensary at the 

Univ. Hospital, Phila., etc. 

HANDBOOK OF DIAGNOSIS AND TREATMENT OF DISEASES OF 

THE THROAT AND NAS.AL CAVITIES. In one handsome royal 12mo. volume, 

of 156 pages, with 35 illustrations ; cloth, $1. (Lately Issued.) 

We most heartily commend this book as showing A convenient little handbook, clear, concise, and 

sound judgment in practice, and perfect faniiliariiy i accurate in its method, and admirably fulfilling its 

with the literature of tlie specialty it so ably epi- \ purpose of bringing the subject of which it treats 

tomizes. — Philada. Med. Times, July 5, 1S79. within ^he comprehension of the general practi- 

I tioner.— iV C. Med. Jour., June, 1879. 

CLINICAL OBSERVATIONS ON FUNCTIONAL HILLIER'S HANDBOOK OF SKIN DISEASES, for 

NERVOUS DISORDERS Bv C. HANnFiEi.D Jone:. Students and Practitioners. Second Am Ed. In 

M.D., Physician to St. Mary's Hnsi)ita], &c. Sec- one royal l2mo. vol. of 358 pp. With illustrations, 

ond America n Edition. In one h^ ndsome octav( Cloth, $2 25. 
vatumeof 346 pages,cloth, $3 25. 



20 Henry C. Lea's Son & Co.'s Publications — ( Venereal Diseases, Sc), 
jyUMSTEAD [FREEMAN J.), M.D.,LL,D., 

"^-^ Late Professor of Venereal Diseases at the Gol. of Phys. and Surg., New York, Sec. 

THE PATHOLOGY AND TI^EATMENT OF VENEREAL DIS- 

EASES. Including the results of recent investigations upon the subject. Fourth Edition, 
revised and largely rewritten with the co-operation of R. W. Taylor, M.D., of New 
York, Prof, of Dermatology in the Univ. of Vt. In one large and handsome octavo 
volume of 835 pages, with 138 illustrations. Cloth, $4 75 ; leather, $5 75; half Russia, 
$6 25. {Noiu Ready.) 



We have to congratulate our countrymen upon 
the truly valuable addition which they have made 
to American literature. The careful esiimate of the 
value of the volume, which we have made, justifies 
us in declaring that this is the best treatise on 
venereal diseases in the English language, and we 
might add, if there is a better in any other tongue 
we cannot name it; there are certainly no books in 
which the student or the general practitioner can 
find such an excellent r^sumi of the literature of 
any topic, and such practical suggestions regarding 
the treatment of the various complications of every 
venereal disease. We take pleasure in repeating 
that we believe this to be the best treatise on vene- 
real disease in the English language, and we con- 
gratulate the authors upon their brilliant addition 
to American medical literature. — Chicago Med. Jour- 
nal and Examiner, February, 1880. 

It i.s, without exception, the most valuable single 
work on all brrinches of the subject of which it treats 
in any language. The pathology is sound, the work 
is, at the same time, in the highest degree practical, 
and the hints that be will get from it for the man- 
agement of any one case, at all obscure or obstinate, 



will more than renay him for the outlay. — Archives 
of Medicine, April, 1S«0. 

This now classical work on venereal disease comes 
to us in its fourth edition rewritten, enlarged, and 
materially improvpd in every way. Dr. Taylor, as 
we had every reason to expect, has performed this 
part of his work with unusual excellence. We feel 
that what has been written has done but scanty jus- 
tice to the merits of this truly great treatise. — St. 
Louis Courier of Medicine, Feb. 18S0 

We find that we have here practically a new book 
—that the statement of the title-page, as to the fact 
that it has been largely rewritten, is a sufficiently 
modest announcement for th« important changes in 
the text. After a thorough examination of the pre- 
sent edition, we can assert confidently that the enor- 
mous labor wf! have described has been here most 
faithfully and conscientiously performed. — Amer. 
Journ. Med. Sci., Jan. 1880. 

It is one of the best general treatises on venereal 
diseases with which we are acquainted, and is espe- 
cially to be recommended as a guide to the treatment 
of syphilis. — London Practitioner, March, 1880. 



G 



yROSS {SAMUEL W.), A.M., M.D., 

Lecturer on Genito-Urinaiy and. Venereal Diseases in the Jefferson Medical College, Phila. 

A PRACTICAL TREATISE ON IMPOTENCE, STERILITY 

A^D ALLIED DrSORDERS OF THE MALE SEXUAL ORGANS. In one very hand 
some octavo volume of 1 74 pages, with 1^ illustrations. Cloth, $1 50. {Just Ready.) 

EXTRACT FROM TU^ AUTHOr's PREFACR. 

"My aim has been to supply, in a compact form, prnetical and strictly scientific information, 
especially adopted to the wants of the general practitioner, in regard to a class of common and 
grave disorders, upon the correction of which so much of human happiness depends. In the 
chapter on Sterility, the abnormnl conditions of the semen and the cause.s which deprive it of 
its fecundating properties are fully considered — a portion of the work intended to supplement 
the subject of sterility in the female. From answers to letters addressed to many of the most 
prominent writers in this country on gynaecology. I find that, with few exceptions, the wom^n 
ainne commands attention in unfruitful marriages. The importance of examining the husband 
before subjecting the wife to operation will be best appreciated when I state that he is, as a 
rule, at fault in at least one example in every six." 

and nUMSTEAD [FREEMAN J.), 

■^-^ Professor of Venereal Diseases in the College of 
Physicians and Surgeons. N. Y . 

AN ATLAS OF VENEREAL DISEASES. Translated and Edited by 

Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, 

with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 

life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers, at $8 per part. 

Anticipating a very large sale for this work, it is offered at the very low price of Three Dol - 

LA.US a Part, thus placing it within the reach of all who are interested in this department of 

practice. Gentlemen desiring early impressions of the plates would do well to order it without 

delay. A specimen of the plates and text sent free by mail, on receipt of 25 cents. 



dlULLERIER [A.) 

^^ Suraeon to the Hopit 



Hopital du Midi. 



LEE'S LECTURES ON SYPHILIS AND SOME 
FORMS OF LOCAL DISEASE AFFECTING PRIN- 
CIPA-LLY THE ORGANS OF GENERATION. In 
one handsome octavo volume; cloih, ^2 2.>. 

GON DIE'S PRACTICAL TREATISE ON THE DIS- 
EASES OF CHILDREN. Sixth edition, revised 
and augmented. In one large octavo volume of 
nearly 800 closely-printed pages, cloth, %o 25 ; 
leather, $6 2.5. 

WILSON'S STUDENT'S BOOK OF CUTANEOUS 
MEDICINE and Diseases of the Skin. la one 
very handsome royal 12mo volume. $.^ .50. 

CHAMBERS'S MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one handsome 
octavo volume. Cloth, $2 75. 

BASE.^M ON RENAL DISEASES : a Clinical Guide 
to their Diagnosis and Treatment. With Illustra- 
tions. In one 12mo. vol. of 304 pages, cloth, -$2 00. 



LECTURES ON THE STUDY OF FEVER. By A. 
Hudson, M.D., M.R.I. A., Physician to the Meath 
Hospital In one vol. 8vo., cloth, $2 50. 

A TREATISE ON FEVER. By Robert D. Lyons, 
K.G.C. I none octavo volume of362 pages, doth 
«2 25. 

HILL ON SYPHILIS AND LOCAL CONTAGIOUS 
DISORDERS. In one handsome octavo volume; 
cloth $3 25. 

SMITH'S PRACTICAL TREATISE ON THE WAST- 
ING DISEASES OF INFANCY AND CHiLDHOOD. 
Second American, from the Second revised and 
enlarged English edition. In one handsome octa- 
vo volnme, cloth, ^'i i^o 

LA ROCHE ON PNEUMONIA. 1 vol. 8vo., clotli, 
of 500 pages. Price, $3 00. 



Henry C. Lea's Son & Co.'s Publications — (Dis. of Children, Sc). 21 
(DMITH {J. LE WIS), M.D., 

Clinienl Prnfessor of BUea.ftpK of Ohildrpn in the Bellevue Hnspital Med College, N.J. 

A COMPLETE PRACTICAL TREATISE OX THE DISEASES OF 

CHILDREN. Fifth Edition, thoroughly revised and reAvritten. In one handsoiwe oc- 
tavo volume of 836 pages, -with illustrations. Cloth, $4 50; leather, S5 50; very hand- 
some half Russia, raised bands, $6. [JiL^t Ready.) 
The opportunity afforded the author by the call for a new edition of his treatise on the Diseases 
of Children has been taken advantage of to render the volume in every respect worthy a contin- 
uance of the profession's confidence with which it has been favored in the past. Many portions 
of the work have been entirely rewritten, several additional diseases treated of, and much new 
matter introduced ; but by the employment of a more condensed style of letter, the size of the 
wcrk has not been materially enlarged. It will be observed that the very moderate price of the 
previous edition has uot been increased. 



'^EATING [JOHN 31.), M.D., 

Lecturer on the Diseaats of Children at the University of Penn.^ylvania, etc. 

THE MOTHER'S GUIDE IN THE MANAGEMENT AND FEED- 
ING OF INFANTS. In one handsome 12mo. vol. of 118 pages. Cloth, $1 00. {Noif? 
Ready. ) 

The lille of this little book is well chosen, and Dr. structing them on the subjects here dwelt so thor- 
Keating has written a work which should be vend, oughly aud practically upon. Dr. Keating has wric- 
and it.s precepts followed by every iutelLigent nio- ten a practical book, has carefully avoided unne- 
ther in thi.s country. It is free from all technical cessary repetition, and, I think, s-ucce>sfnlly in- 
terms, the language is clear and distinct, aud so strncted the mother in such details of the treatment 
carefully written that it caunor fail to become popu- of her child as devolve upon her; he has studiously 
lar. It has always been a mooted question how far omitted giving prescriptions, aud instrucs the mo- 
lt is well to instruct the public, but works like this iher when to call upon the doctor, as his duties are 
one will aid the physician immensely, for it saves totally distinct from hers. — American Journal of 
the time he is constantly giving his patients in in- Obstetrics, October, ISSl. 



yj^EST (CHARLES), M.D., 

Physician to the Hospital for Sick Chi'dren, London, &e . 

LECTURES ON THE DISEASES OF INFANCY AND CHILD- 

HOOD. Fifth American from the Sixth revised and enlarged English edition. In one large 
and handsome octavo volume of 678 pages. Cloth, $4 50 ; leather, $5 50. 

^T THE SAME AUTHOR. ( Lately issued.) 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- 
HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of 
London, in March, 1871. In one volume small 12mo., cloth, $1 00, 



JDY THE SAME AUTHOR. 

LECTURES ON THE DISEASES OF WOMEN. Third Ameiioan, 

from the Third London edition. In one neat octavo volume of about 550 pages, cloth, 
$3 75; leather, $4 75. 



S 



WAYNE [JOSEPH GRIFFITHS), M.I)., 

Physician-Accoticheur to tlie British Gf-neral Hospital, &c. 

OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- 
MENCING MIDWIFERY PRACTICE. Second American, from the Fifth and Revised 
London Edition, with Additions by E. R. Hutchins, M.D. With Illustrations. In one 
neat 12mo. volume. Cloth, $1 25. 



CHURCHILL ON THE PUERPERAL FEYER AND ' MEIGS ON THE NATURE, SIGNS AND TREAT- 
OTHER DISEASES PECULIARTO WOMEN. 1vol. : MENT OF CHILDBED FEVER 1 vol. Svo., pp. 
^vo.. po. 450, cloth. $2 50. | .365. cloth. $2 00. 

DEWEES'^S TREATISE ON THE DISEASES OF FE-I ASHWELL'S PRACTICAL TREATISE ONTEE DIS- 
MALES. With illustrations. Eleventh Edition . | EASES PECULIAR TO WOxMEN. Third American, 
with the Anthor'slastimprovemeatsand correc- ; from the Third andrevised Londonedition. 1vol. 
tions. In one octavo volume of 536 pages, with i 8vo., pp. 52S, cloth. $3 50. 
plates, cloth, $3 00. . I 



TT/INCKEL (F), 

' ' Professor and Director of the Gyncecological Clinic in the University of Rostook. 

A COMPLETE TREATISE OS THE PATHOLOGY AND TREAT- 
MENT OF CHILDBED, for Students and Practitioners. Translated, with the coasent 
of the author, from the Second German Edition, by James Read Chadwick, M.D. In 
one octavo volume. Cloth, $4 00, 



MONTGOMERY'S EXPOSITION OF THE SIGNS RIQBY'S SYSTEM OF MIDWIFERY. With notes 
AND SYMPTOMS OF PREGNANCY. With two | and Additionaj JJustrations. Second Ame.:i<-an 
exquisitoooloredplate.^i. and numerous wood-cutf j edition. One volume octavo, cloti, 422 pages, 
In 1 vol.8vo.,ofiiearly600pp.,cioth,$3 76. I $2 50. 



22 



Henry C. Lea's Son & Co.'s Publications — {Dis. of Women). 



/THOMAS [T.GAILLARD),M.D., 

•*- Professor of Obstetrics, &c.. in the College of Physicians and Surgeons, N. T., Ac 

A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Eifth 

Edition, thoroughly revised and rewritten. In one large and handsome octavo volume 
of over 800 pages, with 266 illustrations. Cloth, $5 ; leather, $6 ; very handsome half 
Russia, raised bands, $6 50. (Just Ready.) 
The author has taken advantage of the opportunity aflForded by the call for a new edition of 
this work to render it worthy a continuance of the very remarkable favor with which it has 
been received. Every portion of the work has been carefully revised, very much of it has 
been rewritten, and additions and alterations introduced wherever the advance of science and 
the increased experience of the author have shown them desirable. At the same time special 
care has been exercised to avoid undue increase in the size of the volume. To accommodate 
the numerous additions a more condensed but V' ry clear letter has been used, notwithstanding 
which, the number of pages has been increased by more than fifty. The series of illustrations 
has been extensively changed ; many which seemed to be superfluous have been omitted, and a 
large number of new and superior drawings have been inserted. In its improved form, there- 
fore, it is hoped that the volume will maintain the character it has acquired of a standard 
authority on every detail of its important subject. 

An examination of the work will satisfy that it is 
one of great merit. It is not a mere compilation 
fri)m other works, but is the fruit of the ripe 
thought, sound judgment, and critical observations 
of a letrned, scientific man. It is a treasury of 



knowledge of the department of medicine to which 
it is devoted. In its present revised state it cer- 
tainly hold.'! a foremost positioa as a gynajcological 
work, and will continue to be regarded a.-^ a stan- 
dard authority — Cincinnati Med. News, Dec. 18S0, 
This work needs no introduction to any of the 
civilized nations of the world. The edition before 
us adds to the strength of former volumes. With 
the wisdom of a master teacher he here gives the 
results that, in his judgment, are most trustworthy 
at the present time. In its owu place it has no 
rival, because the author is the best teacher on this 
subject 10 the masses of the profession As hitherto 
this work will be the text-book on dipeases of wo- 
men We only wish that in other branches of medi- 
cine as capable teachers could be found to write our 
text-books, — Detroit Lancet, Jan. ISSI. 



Since its first appearance, twelve years ago, until 
the pre-ent day, it has held a position of high re- 1 .' 
'ded to be one of the ^ 



gard, and is generally concede 
most practical and trustworthy volumes yet pre- 
sented to the physician and student in the depart- 
ment of gynaecology. The woi k embodies not only 



its authoi-'s large experience, but reflects his care- 
ful study among other authorities in this bi anch, 
both at home and abr-«ad Dr. Thomas is an able 
and conscientious teacher. His writings convey 
his me;tningin the .'-^ame practical and instructive 
manner. The last edition of this work is fresh from 
his pen, with decided changes and iranrovements 
over former editions. His book presents generally 
accepted facts, and a^ a guide to t he student is more 
useful and reliable than any work in the language 
on diseases of women. This last edition will ^idd 
new laurels to those already won. — Md. Med. 
Journ., Nov. 15, 1880. 

It has been enlarged and carefully revised. The 
author has brought it fully abreast with the times, 
and as the wave of gynecological progresssion has 
been widespread and rapid during the twelve years 
that, have elapsed since tbeissue of the first edition, 
one can conceive of the great improvement this edi- 
tion must be upon the earlier. It is a condensed en- 
cyclopjedia of gynsecological medi.ine. The style of 
arrangement, the maUerly minner in which each 
subject is treated, and the honest convictions de- 
rived from probably ths Ursjest clitnical experience 
n that specialty of any in this country, all serve to 



commend it in the highest terms fo the practitioner. 
—Nashville Journ. of Med. and Sury., Jan. 1881. 



E 



DIS [ARTHUR W.), M.D. Lond., F.R.C.P., M.R.C.S. 

Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital. 

THE DISEASES OF WOMEN. Including their Pathology, Causa- 

tion, Symptoms, Diagnosis, and Treatment. A manual for Students and Practitioners. 
In one handsome octavo volume with 149 illustrations. {Shortly.) 

JDARNES [ROBERT), M.D., F.R.C.F., 

^-^ Obstetric Physician to St. Thomas'' s Hospital, &c. 

A CLINICAL EXPOSITION OF THE MEDICAL AND STJRCI- 

CAL DISEASES OF WOMEN. Second American, from the Second Enlarged and Revised 
English Edition. In one HandRom« octavo volume, of 784 pages, with 181 illustrations. 
Cloth, $4 50; leather, $5 50; half Russia, $6. {Lately Isstied.) 

Dr. Barnes stands at the head of his profession in 
the old country, and it requires but scant scrutiny 
of his book to show that it has been sketched by a 
master. It is plain, practical common sense ; shows 
very deep research without being pedantic ; is emi- 
nently calculated to inspire enthusiasm without in- 
culcatitig rashness; points out the dangers to be 
avoided as well as the success to be achieved in the 
various operations connected with this branch of 



plexity of the man of mature years. — Canadian 
Journ. of Med. Science, Nov. 1878. 

Dr. Barnes's work is one of a practical character, 
largely illustrated from cases in his own experience, 
but by no means confined to such, as will be learned 
from the fact that he quotes from no less than 628 
taedical authors in numerous countries. Coming 
'rom such a.n author, it is not necessary to say that 
, , the work is a valuable one, and should be largely 

medicine; and will do much to smooth the rugged i consulted by the profession.— /Im. Svpp Obstetrical 
path of the young gynaecologist and relieve the per- 1 j-o?/rn. Gt. Britain and Ireland, Oct, 1S78. 



H 



ODGE (HUGH L.), M.D., 

Emeritus Professor of Obstetrics, &c., in the University of Pennsylvania. 

ON DISEASES PECULIAR TO WOMEN ; including Displacements 

of the uterus. With original illustrations. Second edition, revised and eiil..^rged. In 
one beautifully printed octavo volume of 531 pages, cloth, $4 50. 



Henry C. Lea's Son & Co.'s Publications — {Dis.of Women'). 



23 



PMMET {THOMAS ADDIS), M.D., 

-*-^ Sitrgeonto the. Woman'' s Hospital, New Tork,etr.. 

THE PRINCIPLES AND PRACTICE OF GYNAECOLOGY, for the 

use of Students and Practitioners of Medicine. Second Edition. Thorougly Revised. 
In one large and very handsome octavo volume of 875 pages, with 133 illustrations. 
Cloth, $6; leather, $6 ; half Russia, raised bands, $6 60. {J2ist Ready.) 



Preface to the Second Edition. 
The unusually rapid exhaustion of a large edition of this work, while flattering to the author 
as an evidence that his labors have proved acceptable, has in a great measure heightened his 
sense of responsibility. He has therefore endeavored to take full advantage of the opportunity 
afforded to him for its revision. Every page has received his earnest scrutiny; the criticisms 
of his reviewers have been carefully weighed ; and while no marked increase has been made in 
the size of the volume, several portions have been rewritten, and much new matter has been 
added. In this minute and thorough revision, the labor involved has been much greater than 
is perhaps apparent in the results, but it has been cheerfully expended in the hope of rendering 
the work more worthy of the favor which has been accorded to it by the profession. 



In no country of the world has gynseGology re- 
ceived more attention than in America. It is, then, 
with a feeling of pleasure that we welcome a work 
on diseases of women from so eminent a gynsecolo- 
gist as Dr. Emmet, and the work is essentially clini- 
cal, and leaves a strong imprests of the author's in- 
dividuality. To criticize, with fhe care it merits, 
the book throughout, would demand far more space 
than is at our command. In parting, we can say 
that the work teems with original ideas, fresh and 
valuable methods of practice, and is written in a 
clear and elegant style, worthy of the literary repu- 
tation of the country of Longfellow and Oliver Wen- 
dell Rolmes.— Brit. Med. Journ. Feb. 21, 18S0. 

No gynaecological treatise has appeared which 
contains an equal amount of original and useful 
matter; nor does the medical and .-nrgical history 
of America include a book morft novel and useful. 
The tabular and statistical information which it 
contains is marvellous, both in quantity and accu- 
racy, and cannot be otherwise than invaluable to 
future investigators. It is a work which demands 



not careless reading but profound study. Its value 
as a contribution to gynfecology is, perhaps, greater 
than that of all previous literature on the subject 
combined. — Chicago Med. Gaz., April 6, ISSO 

The wide reputation of the author makes its pub- 
lication an event in the gynaecological world ; and 
a glance through its pages shows that it is a work 
to be studied with care. ... It must always be a 
work to be carefully studied and frequently con- 
sulted by those who practise this branch of our pro- 
fession. — Lond. Med. Times and Gaz., Jan. 10, 18-0. 

The character of the work is too well known to 
require extended notice— sufSce it to say that no 
recent work upon any subject has attained such 
great popularity so rapidly. As a work of general 
reference upon the subject of Diseases of Women it, 
is invaluable. As a record of the largest clinical 
experience and observation it has no equal. No 
physician who pretends to keep up with the ad- 
vances of this department of medicine can afford to 
be without it. — Nashville Journ. of Medicine and 
Surgery, May, 1880. 



I) 



UNCAN [J. MATTHEW^, M.D., LL.D., F.R.S.E., etc. 

CLINICAL LECTURES ON THE DISEASES OF WOMEN, 

Delivered in Saint Bartholomew's Hospital. In one very neat octavo volume of 173 
pages. Cloth, $1 60. (Just Ready.) 



They are in every way worthy of their author ; 
indeed, we look upon them as among ttie most valu- 
ab e of his contributions They are all up >n mat- 
ters of great interest to the general practitioner. 
Some of them deal wi;h subjects that are not, as a 
rule, adequately handled in the text-books ; others 
of them, while iaearing upon topics that are usually 
treated of at length in such works, yet bear such a 
stamp of individuality that, if widely read, as they 
cert^ialy deserve to bft, they canuot fail to exert a 
wholesome restraint upon the undue eagerness with 
which many young physicians seem bent upon fol- 
lowiug the wild teachings which so infest the gynje- 
cology of the present day. — N. T. Med. Journ., 
March, 1880. 



The author is a remarkably clear lecturer, and 
his discussion of symptoms and treatment is full 
and suggestive. It will be a work which will nut 
fail to be read with benefit by practitioners as well 
as by students. — PAi7a. Med. and Surg. Reporter, 
Feb. 7,1880. 

We have read this book with a great deal of 
pleasure. It is full of good things. The hints on 
patholugv aud ti'eaimeat scattered through the book 
are sound, trustworthy, and of great value. A 
healthy scepticism, a lai-ge experience, and a clear 
judgraeut are everywhere manifest. Instead of 
bristling with advice or doubtful value and un- 
sound character, the book is in every respect a safe 
guide. — The London Lancet, Jan. 21, 1860. 



TfAMSBOTHAM [FRANCIS H.), M.D. 

THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 

CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged 
edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., 
Professor of Obstetrics, &o., in the Jefferson Medical College, Philadelphia. In one birce 
and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised 
bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in 
all nearly 200 large and beautiful figures. $7 00 



P 



ARRY [JOHN S.), M.D., 

Obstetrician to the Philadelphia. Hospital, Viee-Prest of the Oh.^tet. S'>eiety of Philadelphia. 

EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, 

DIAGNOSIS, PROGNOSIS AND TREATMENT. In one handsome octavo volume. 
Cloth, $2 50. 

/TANNER {THOMAS H.), M.D. 

ON THE SIGNS AND DISEASES OF PREGNANCY. First American 

from the Second and Enlarged English Edition, With four colored plates and illustra- 
tions on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. 



24 Henry C. Lea's Son & Co.'s Publications — {Midwifery), 



TEISRMAN {WILLIAM), M.D., 

Regius Professor of Midwifery in the University of Glasgow, &c. 

A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF 

PREGNANCY AND THE PUERPERAL STATE. Third American edition, revised by 
the Author, with additions by John S. Parry, M.D., Obstetrician to the Philadelphia 
Hospital, &c. In one large and very handsome octavo volume, of 733 pages, with over 
two hundred illustrations. Cloth, $4 50; leather, $5 50 ; half Russia, $6. {Jiist Ready ) 



Few works on this subject have met with as great 
a demand as this one appears to have. To judge 
by the frequency with which its author's views are 
quoted, and its statements referred to in obstetrical 
literature, one would judge that there are fewphy- 
sicians devoting much attention to obstetrics who 
are without it. The author is evidently a man of 
ripe experience and conservative views, and in no 
branch of medicine are these more valuable than in 
this. — Neiv Remedies, Jan. ISSO. 

We gladly welcome the new edition of this excel- 
lent text-book of midwifery. The former editions 
have been most favorably received by the profes- 
sion on both s'des of the Atlantic In the prepara- 
tion of the present edition the author has^ made such 
alterations as the progress of obstetric il science 



seems to require, and we cannot but admire the 
ability with which the task has been performed. 
We consider it an admirable text-book for students 
during their attendance upon lectures, and have 
great pleasure in recommending it. As an exponent 
of the midwifery of the present day it has no supe- 
rior in the English language. — Canada Lancet , Jan. 
1680. 

To the American student the work before us must 
prove admirably adapted, complete in all its parts, 
essentially modern in its teachings and with dem- 
onstrations noted for clearness and precision, it will 
gain in favor and be recognized as a work of stand- 
ard merit. The work cannot fail to be popular, and 
is cordially recommended.— i\r. 0. Med. and Surg. 
Journ., March, 1S80. 



pLAYFAIR ( W. S.\. M.D., F.R.G.F., 

-^ Professor of Obsteti'ic Medicine in King^s College, etc. etc. 

A TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. 

Third American edition, revised by the author. Edited, with additions, by Robert P. 
Harris, M.D. In one handsome octavo volume of about 700 pages, with nearly 2C0 
illustrations. Cloth, $4 ; leather, $5 ; half Russia, $5 50. (^Jiist Ready.) 
The medical profession has now the opportunity 



of adding to their stock of standard medical works 
one of the best volumes on midwifery ever published. 
The subject is taken up with a master hand. The 
part devoted to labor in all its various presentations, 
the management and results, is admirably arranged, 
and the views entertained will be found essentially 
modern, and the opinions expressed trustworthy 
The work abounds with plates, illustrating various 
obstetrical positions; they are admirably wrought, 
and afford great assistance to the student.— iV^. 0. 
Med. and Surg. Journ., March, 1S80. 

If inquired of by a medical student what work on 
obstetrics we should recommend for him, as par 
excellence, we would undoubtedly advise him to 
choose Playfair's. It is of convenient size, but what 
is of chief importance, i*s treatment of the various 
subjects is concise and plain. While the discussions 
and descriptions ai'e sufficiently elaborate to render 



a very intelligent idea of them, yet all details not 
necessary for i full understanding of the subject are 
omitted. — Cincinnati Med. News, Jan. 1880. 

The rapidity with which one edition of this work 
follows another is proof alike of its excellence and 
of the estimate that the profession has formed of it. 
It is indeed so well known and so highly valued 
that nothing need be said of it as a whole. All 
things considered, we regard this treatise as the very 
best on Midwifery in the English language.— i*/. Y. 
MedicnlJournal, May, 1880 

It certainly is an admirable exposition of the 
Science and Practice of Midwifery. Of course the 
additions made by the American editor. Dr. E. P. 
Harris, who never utters an idle word, and whose 
studious researches in some special departments of 
obstetrics are so well known to the profession, are 
of great value. — The American Practitioner, April, 
1880, 



J^ARNES (FANCOURT), M.D., 

-*-^ Physician to the General Lying-in Hospital, London. 

A MANUAL OF MIDWIFERY FOR MIDWIFES AND MEDICAL 

STUDENT -<. With 50 illustrations. In one neat royal 12mo. volume of 200 pages; 
cloth, $1 25. {Noiv Ready.) 

T>ARVIN {THEOPHILU.'i), 31. D., 

Prof, of Obstetrics and of the Med. and Surg. Diseases of Women in the Med. Coll. of Indiana. 

A TREATISE ON MIDWIFERY. In one very handsome octavo 

volume of about 550 pages, with numerous illustrations. {^Prefaring.) 

ODGE [HUGH L.), M.D., 

Ew.eHtus Professor of Midwifery, &e., in the University of Pennsylvania, &c. 

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- 
trated with large lithographic plates containing one hundred and fifty-nine figures from 
orio'inal photographs, and with numerous wood-cuts. In one large and beautifully printed 
quarto volume of 550 double-columned pages, strongly bound in cloth, $14. 

body in a single volume the whole science and art of 
Obstetrics. An elaborate text is combined with ac- 
curate and varied pictorial illustrations, so that no 
fact or principle Is left unstated or unexplained. 
—Am. Med. Times, Sept. ,3, 1864. 

*^ Specimens of the plates and letter-press will be forwarded to any address, free by mail, 



B 



The work of Dr. Hodge is something more than 
a simple presentation of his particular views in the 
dejartment of Obstetrics; it is something more 
than an jrdinarytreatise on midwifery; it is, in fact, 
a cyclopaedia of midwifery. He has aimed to em- 



* ":^ 



on receipt of six cents in postage stamps 

rfHAD WICK [JAMES R 






A.M., M.D. 
A MANUAL OF THE DISEASES PECULIAR TO WOMEN. In one 

neat volume, royal 12mo., with illustrations. {Preparing.) 



Henry C. Lea's Son & Co.'s Publications — (Surgery). 



25 



TJAMILT.ON [FRANK H.) M.D., LL.D.. 

J- J- Surgeon t<t the £p.llevi'.e Hnsjntal, New York. 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 

TIONS Sixth Edition, thoroughly revised, and mur^h improved. In one very handsome 
octavo volume of over 900 pages, -with 352 illustrations. Cloth, $5 50; leather, §6 50; 
half Russia, raised bands, Sf 00. {Just Ready.) 
So many kind expressions oi welcome have been | Dr Hamilton has devoted great labor :o the study 

of these sabjects. His large experience, extended 



showered upon each successive edi ion of this val 
uable treatise, that scarcely nnyihing iemains for 
us to do but to ex end the castomnry cordial greet- 
ing. It is the only complete work on the subject 
of Fractures in the English language. We con- 
grainlate the accomplished author on the deserved 
success of his work, and hope tha: he may live to 
havemany .-uccecding editions pas- under his skill- 
ed super-vision. — Phila. Coll. a,nd Clin. Record, 
^"ov. 1.5, ISSO. 

Universal verdict has pronounced it, humanly 
speaking, a perieit treat se upon this subject. As 
it is the only complet • and illustrated work in any 

language tre^ ting of fracture- and dislocations, it i proved. The work 
is safe to affirm that every wide-awrtke surgeon and I surgery, and will 1 



general practitioner will regard it as iudispen.sable 
to the safe and pleasant conduct of their profes- 
sional work. — Detroit Lancet, j!{ov. IS, ISSO. 



research, :nd patienr investigation Lave made him 
one of the highe>t authoriiics among living writers 
in this branch of surgery This work is systematic 
and prai t^cai in Its arrangement, anu presents its 
subject jnatter rleyriy and forcibly to the reader 
or stxiAent.— Maryland Medic alj'ournal, Ihov.15, 
ISSO. 

The only complete work on its subject in theEng 
lish tongue, and, indeed, may now be said to be 
the only work of its kind in any tongue. It would 
require an exceedingly critical examination to de- 
tect in it any particulars in which t might be im- 
mouument to American 
:rve to keop green ihe 



memory of its venerable author.— JfiCiZt^aw Med. 
Few8, 1sj\. 10, ISSi. 



A SHHURST [JOHN, Jr.), M.D. 

-^-*- Prof, nf Clinical Surgery. Univ. of Pa 



Prof, nf Clinical Surgery. Univ. of Pa., Surgeon to the Episcopa I Hospital, Philadelphia. 

THE PRINCIPLES AND PRACTICE OE SURGERT. Second 

Edition, enlarged and revised. In one very large and handsome octavo volume of over 

1000 pages, with 542 illustrations. Cloth, $6; leather, 87: half Russia, $7 50. {Just 

Issued.) 

Conscientiousness and thoroughness are two very | language all that is necessary to be learned by the 

marked traits of character in the author of this j student' of surgery whilst in" attendance upon lec- 



book. Out of these traits largely has grown th 
success of his mental fruit in the past, and the pre- 
sent offer seems in no wise an exception to what has 
gone before. The general arrangement of the vol- 
ume is the same as in the first edition, but every part 
has been carefully revised, and much new matter 
added.— P/iiZa. Med. Times, Feb. 1, 1S79. 

The favorable reception of the first edition is a 
guarantee of the popularity of this edition, which is 
fresh from the editor's hands with many enlarge- 
ments and improvements. The author of this work 
is deservedly popular as an editor and writer, and 
his contributions to the literature of surgery have 
gained for him wide reputation. The volume now 
offered the profession will add new laurels to those 
already won by previous contributions. We can 
only add that the work is well arranged, filled with 
practical matter, and contains in brief and clear 



tures, or the general practitioner in his daily routine 
practice.— J/'<. Med. Journal, Jan. 1S79. 

The fact that this work has reached a second edi- 
tion so very soon after the publication of the first 
one, speaks more highly of its merits than anything 
we, might say in the way of commendation. It 
seems w have immediately gained the favor of stu- 
dent.s and physicians. — Cincin. Med. iVew-S, Jan. '79. 

We have previously spoken of Dr. Ashhurst's 
work in term.? of praise. We wish to reiterate those 
terms here, and to add that no more satisfactory 
representation of m-^dern surgery has yet fallen 
from the press. In point of jud'icial fairness, of 
power of condensation, of accuracy aud conciseness 
of expression and thoroughly good English, Prof. 
Ashhurst has no superior among the surgical writers 
in America. — Am. Practitioner, Jan. 1S79. 



j^TUlSON [LEWIS A.), A.M., M.B., 

^ Surgeon to the Presbyterian Hospital. 

A MANUAL OF OPERATIVE SURGERY. In one very handsome 

royal 12mo. volume of about 500 pages, with 332 illustrations ; cloth, $2''50. 

The work before us is a well printed, profusely performing them. The work is handsomely illus- 
lllustrated manual of over four hundred and seventy trated, and the de? criptions are clear and well'drawn. 
pages. The novice, by a perusal of the work, will It is a clever aud useful volume; every student 
gain a good idea of the general domain of operative should possess one. The preparation of this work 
surgery, while the practical surgeon has presented does away with the necessity of pondering over 
to him within a very concise and intelligible form ; larger works on surgery for descriptions of opera- 
the latest and most approved selections of operative tions, as it presents in a nut-shell just what is wanted 
procedure. Theprecision at d conciseness with which .by the surgeon without an elaborate search to find 
the different operations are described enable the ix.—Md. 3fed Journal. Aug. 1S7S. 
author to compress an immense amount of practical i ^he author's conciseness and the repleteness of 
inrormation ma very smaU compass.-iv. T. Meaical t^e work with valuable illustrations entitle it to be 
decora, Aug. a, i&/&. ; classed with the text-books for students of operative 

This volume is devoted entirely to operative sur- surgery, and as one of reference to the practitioner, 
gery, and is intended to familiarize the student with — Oincinnati Lancet and Clinic, July 27, 1S7S. 
the'details of operations and the different modes of 



■SKEY'S OPERATIVE SIIRGEBT. In 1 vol. Svo. 
cl., of650pages ; with about 100 wood-outs. $3 25. 

COOPER'S LECTURES OIn THEPRUy'dPLES AND 
Practice OF Surgery. Inl vol. Svo.cl'h. 750 p. $2. 

GIBSOI^'SINSTITUTES AISD PRACTICE OF SUR- 
GERY. Eighth edit'n, improved and altered. With 
thirty-four plates. In two handsome octavo vol- 
umes". about 1000pp. .leather, raised bands. *6 50. 

THE PRINCIPLES AlJf D PRACTICE OF SURGERY. 
By William Pirrie.F.R S E., Profes'r of Surgery 
in the University of Aberdeen. Edited by John 



N BILL, M.D. , Professor of Surgery in the Penna. 
MedicalCollege.Surg'n to the Pennsylvania Hos- 
pital, <kc. In one very handsome octavo vol. of 
780 pages, with 316 illustrations, cloth, $.3 75. 
MILLER'S PRINCIPLESOf SURGERY. Fourth Ame- 
rican, from the Third Xdiiiburgh Edition. In one 
large Svo. vol. of 700 pages, with 340 illustrations 
! cloth, -$3 75. ' 

' MILLER'S PRACTICE OF SURGERY. Fourth Ame- 

j ric»u. from the last Edinburgh Edition Revised by 
: the American editor In on(»iarge 5vo. vol. of nearly 
j TOO pages, with 864 illustrationc : cloth, $3 75. 



Henry C. Lea's Son & Co.'s Publications — (Surgery). 



f_fBOSS {SAMUEL D.), M.D., 

^-^ Professor of Surgery in the Jefferson Medical College of Philadelphia. 

A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic 

and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth editioif, 
carefully revised and improved. In two large and beautifully printed imperial octavo vol- 
umes of about 2300 pp., strongly bound in leather, with raised bands, $15; half Russia, 
raised bands, $16. 



We have seldom read a work with the practical 
value of which we have been moreimpressed. Every 
chapter is so concisely put together, that the busy 
practitioner, when in difficulty, can at once find the 
information he requires. His work is cosmopolitan, 
the surgery of the world being fully represented in it. 
The work, in fact, is so historically unprejudiced, and 
so eniinentlypractical,thatitis almost a false compli- 
ment to say thatwe believe it to be destined to occupy 
a foremost place as a work of reference, while a system 
of surgery like the present system of surgery is the 
practice of surgeons. The printingand binding of the 
work is unexceptionable; indeed, it contrasts, in the 
latter respect, remarkably with English medical and 
surgical cloth-bound publications, which are generally 
80 wretchedly stitched as to require re- binding before 
they are any time in use. — Duh. Journ. of Mtd. Set.. 
March, 1874. 

Dr. Gross's Surgery, a great work, has become still 
greater, both in size and merit, in its mostrecent form. 
The difference in actual number of pages is not more 
than 130, but. the size of the page having been in- 
creased to what we believe is technically termed "ele- 
phant,"there has been roomforconsiderableadditions, 
which, together with the alterations, are improve- 
ments. — Lond. Lancef, Nov. 16, 1872. 

It combines, as perfectly as possible, the qualities of 
a text-book and work of reference. We think this last 
edition of Gross's "Surgery," will confirm his title ol 



" Primus inter Pares." It is learned, scholar-like, me- 
thodical, precise, and exhaustive. We scarcely think 
any living man could write so complete and faultless a 
treatise, or comprehend more solid, instructive matter 
in the given number of pages. The labor must have 
been immense, and the work gives evidence of great 
powers of mind, and the highest order of intellectual 
discipline and methodical disposition and arrangement 
of acquired knowledge and personal experience. — iV.Z. 
Med. Journ., Feb. 1873. 

As a whole, we regard the work as the representative 
"System of Surgery" in the English language. — St. 
Louis Medical and Surg. Journ., Oct. 1872. 

The two magnificent volumes before us afford a very 
complete view of the surgical knowledge of the day. 
Some years ago we had the pleasure of presenting the 
first edition of Gross's Surgery to the profession as a 
work of unrivalled excellence; and now we have the 
result of years of experience, labor, and study, all con- 
densed upon the great work before us. And to students 
or practitioners desirous of enriching their library with 
a treasure of reference, we can simply commend the 
purchase of these two volumes of immense research. — 
Oincinnati Lancet and Observer, Sept.lS72. 

A complete system of surgery — not a mere text-book 
of operations, but a scientific accountof surgical theory 
and practice in all its departments. — Brit, and For. 
Med. CAir.iJer., Jan. 1873. 



-Atlanta Med. Journ., Oct, 



JDY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE DISEASES, INJURIES 

and Malformations of the Urinary Bladder, the Prostate Gland and the Urethra. Third 
Edition, thoroughly Revised and Condensed, by Samuel W. Gross, M.D., Surgeon to 
the Philadelphia Hospital. In one handsome octavo volume of 574 pages, with 170 illus- 
trations: cloth, $4 60. 
For reference andgeneral information, the physician 
orsurgeon can find no work that meets their necessities 
more thoroughly than this, a revised edition of an ex- 
cellent treatise, and no medical library should be with- 
out it. Replete with handsome illustrations and good 
ideas, it has the unusual advantage of being easily 
comprehended, by the reasonableand practical manner 
in which the various subjects are systematized and 
arranged We heartily recommend it to the profession 
as a valuable additionto the importantliterature of dis- 



eases of the urinary organs.- 
1876. 

It is with pleasure we now again take up this old 
work in a decidedly new dress. Indeed, it must be re- 
garded as a new book in very many of its parts. The 
chapters on "Diseases of the Bladder," "Prostate 
Body," and "Lithotomy," are splendid specimens of 
descriptive writing; while the chapter on "Stricture" 
is one of the most concise and clear that we have ever 
read. — New York Med. Journ., Nay .ISl 6. 



jyY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON FOREIGN BODIES IN THE 

AIR-PASSAGES. In 1 vol. 8vo., with illustrations, pp. 468, cloth, $2 75. 
pOLEMAN [ALFRED], L.R.C.R, F.R.C.S., L.D.S., etc. 

Senior Dental Surgeon, and Lecturer on D -ntal Surgery to St. Bartholomew' s Hospital and the 
Dental College of London. 

• A MANUAL OF DENTAL SURGERY AND PATHOLOGY. 

Thoroughly revised and adapted to the use of American students, by Thomas G. Stell- 
wagen, M.A., M.D., D.D.S., Professor of Physiology at the Philadelphia Dental College. 
In one handsome volume with about 450 illustrations. {In Press.) 

RUITT [ROBERT], M.R.C.S., Src. 

THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 

A newand revised American, from the Eighthenlarged and improved London edition. Illus- 
trated with four hundred and thirty -two wood engravings. In one very handsome octavo 
volume, of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $5 00. 
InMr.Druitt'sbook, though containing only some can say that thissaccessis well merited. His boob, 

moreover, possesses the inestimable advantages of 



D 



seven hundred pages, both the principles and the 
practice of surgery are treated, and so clearly and 
perspicuonsly,a8 to elucidate everyimportant topic. 
We have examined thebook most thoroughly, and 



having the subjects perfectly well arranged and 
classified and of being written in a style at once 
clear md succinct. — Am. Journalof Med. Sciences 



kSHTON ON THE DISEASES, INJURIES, and MAL- 
FORMATIONS OF THE RECTUBI AND ANUS: 
with remarks ou Habitual Constipation. Second 
American, from the Fourth and enlarged London 
Edition. With lllUHtraiions. In one Svo. vol. of 
287 pages, cloth, $3 26. 



SARGENT ON BANDAGING AND OTHER OPERA- 
TIONS OF MINOR SURGERY. New edition, with 
an additional chapter on Military Sargery. One 
l2mo. vol. ot383pag36 withl84 wood-cuts Cloth, 
$175. 



Henry C. Lea's Son & Co.'s Publications — (Surgery). 



27 



JJOLMES [TIMOTHY], 31. A., 

-*-^ Surgeon and Lecturer 07i Surgery at St. Genrge^s Hospital, London. 

A SYSTEM OF SURGERY; THEORETICAL AND PRACTICAL. 

In Treatises by various authors. American Edition, Thoroughly revised and 
REWRITTEN bv JoHN H PACKARD, M.D., SurgeoD to the Episcopal and St. Joseph's Hospi- 
tals, Philadelphia, assisted by a large corps of the most eminent American surgeons. In 
three large and very handsome imperial octavo volumes of about 1000 pages each, with over 
1000 illustrations on wood and thirteen lithographic plates, beautifully colored. [Sold 
only by snb script io7i.) Price per volume, in cloth, ii^G 00; in leather, ^1 00; in half 
Russia, $7 50. Per set, in cloth, $18 00 ; in leather, $21 00 ; in half Kussia, $22 50. 
Volume I. {now ready) contains General Pathology, Morbid Processes, Injuries in 

General, Complications of Injuries and Injuries of PtEGJONS. 
Volume II. {nearly ready) contains Diseases of Organs of Special Sense, Circulator;y 

System, Digestive Tract and Genito-urinary Organs. 
Volume III. {shortly) contains Diseases of the Respiratory Organs, Joints, Bones, and 
Muscles, Operative and Minor Surgery, Gunshot Wounds, Hospitals and Miscel- 
laneous Subjects. 
This great work, issued some years since in England, has won such universal confidence 
wherever the language is spoken, that its republication here, in a form more thoroughly 
adapted to the wants of the American practitioner, has seemed to be a duty owing to the pro- 
fession. 

To accomplish this, the aid has been invited of thirty-three of the most distinguished gentle- 
men, in every part of the country, and for more than a year they have been assiduously engaged 
upon the task. Though the original work presents the combined labor of the most eminent 
members of all the most prominent schools of England, yet the lapse of time since the appear- 
ance of the last edition, the progress of science, and the peculiarities of American practice, 
have rendered necessary a most careful, thorough, and searching revision. Each article has 
been placed in the hands of a gentleman specially competent to treat its subject, and no labor 
has been spared to bring each one up to the foremost level of the times, and to adapt it thor 
oughly to the practice of the country. In certain cases, this has rendered necessary the sub- 
stitution of an entirely new essay for the original, as in the case of the articles on Skin Diseases, 
and on Diseases of the Absorbent System, where the views of the authors have been superseded 
by the advance of medical science, and new articles have therefore been prepared by Drs. Arthur 
Van Harlingen and S. C. Busey, respectively. So also in the case of Anaesthetics, in the use 
of which American practice differs from that of England, the original has been supplemented 
with a new essay by J. C. Reeve, M.D., treating not only of the employment of ether and 
chloroform, but of the other anaesthetic agents of more recent discovery. The same careful 
and conscientious revision has been pursued throughout,- leading to an increase of nearly one- 
fourth in matter, while the series of illustrations has been more than doubled, and the whole 
is presented as a complete exponent of British and American Surgery, adapted to the daily 
needs of the working practitioner 

In order to bring it within the reach of every member of the profession, the five volumes of 
the original have been compressed into three, by employing a double-columned imperial octavo 
page, and in this improved form it is offered at less than one-half the price of the original. It 
is beautifully printed on handsome laid paper and forms a worthy companion to Reynolds's 
" System of Medicine," which has met with so much favor in every section of the country. 

The work will be sold by subscription only, and in due time every member of the profession 
will be called upon and offered an opportunity to subscribe. 

The few notices appended will serve to indicate the hearty approval accorded to the unrevised 
edition on its appearaLce some years since : — 



There is so much that is instructive, even to the 
experienced practitioner, in their practical and dis- 
criminating manner of aeaLing with mooted ques- 
tion*, none of which seem to be neglected; their 
abundant illastratious, drawn at once from an un 
limned field of hospital experience, aud their candid 
and sensible mode of handling the whole subject, 
that these particular portions of the work possess a 
value wnich places them far above any publication 
on the same topics yet issued in the language. —-4m. 
Journ. Med. Sciences. 

The enumeration of the treatises, and the names 
of the surgical writers from whose pens they pro- 
ceed, suffice to show that this is no ordinary book, 
and that in the thousand pages of this goodly volume 
lies a store of information such as no other surgical 
wjik in the language can pretend to oflFer. Those wLo 
are acquainted with the special researches and pub- 
licatit)ns of the respective authors will not fail to 
notice that by a judicious exercise of editorial dis- 
cretion, each subject has been entrusted, as far as 
possible, to a surgeon of the hospitals who is known 
to have given especial attention to it, and to possess 
facilities for summing up with authority the accepted 
opinions of the day, and adding original matter to 
the stock. — London Lanctt. 

The work must be considered a very complete ac- 
count of everything connected with the science and 
practice of surgery. In conclusion we can cordially 
recommend this work as a valuable addition to the 



library of the surgeon. — Edinburgh Medical Jour- 
nal. 

It is a cyclopsedia of surgery of the most complete 
and extensive character; and we may justly state 
that its design aud execution do great honor to those 
concerned, and that the large number and high 
standing of the authors selected for the various 
monographs render this "System" what it no doubt 
was intended to be, representative of the actual state 
of surgical science and art in the country. — London 
Lancet. 

In conclusion, we will add that we can most con- 
scienciously recommend the book to every medical 
practitioner. In recommending the "Sysifemn/jS'M - 
^erj/" to our friends who have to deal in surgical 
cases, we by no means wish to confine our recom- 
mendation to them alone. Every practitionei of 
medicine may cull something worthy of note from a 
perusal of this volume.— The Britisk Med. Journal. 

The four volumes remain a monument to the sur- 
gical genius of our day. The great majority of rae- 
tropolitau surgeons of eminence and proved ability 
are represented in them ; and for many years to 
come, whoever wishes to know the most authori- 
tative words of English Surgical science on most 
subjects in the domain of surgery, must turn to these 
pages to read what there is set forth, but taken as 
a whole itis the mostimportant surgical work which 
has ever issued from the English press.— iojtdon 
Lancet, 



28 Henry C. Lea's Son & Co.'s Publications — (Surgery), 

f^EFANT {THOMAS), F.R.C.JS., 

'^ Surgeon to Guy's Hospital. 

THE PRACTICE OP SURGERY. Third American, from the Sec- 

ond and Revised English Edition. Thoroughly revised and much improved, by John B. 
Roberts, M.D. In one large and very handsome imperial octavo volume of over 1000 
pages, with 672 illustrations. Cloth, $6 60; leather, $7 50 ; very handsome half Russia, 
raised bands, $8 00. {Just Ready.) 

the whole work has been carefully revised, much 

t liHS beeu rewritten, important additions have 

to almost every chapter. — Oiiicinnati 



Mr. Bryant's work has long been a favorite one 
with surgeons. As its name indicates, it is of a tho- 
roughly practical character. It is distinctly indi- 
vidual in that it gives the results of the author's 
large and varied experience as an operator and cli- 
nical teacher, and is on that account prized deserv- 
edly high as an original work. The style is neces- 
sarily condensed, the descriptions of surgical dis- 
eases brief and to the point. The illustrations are 
well chosen, and the typical cates of the author's 
experience are full of interest, and are of more than 
ordinary value to the working surgeon.— A". Y. 
Medical Record, March 5, ISSl. 

It is a work especially adapted to the wants of 
students and practitioners. "While not prolix, it 
affords instruction in sufficient detail for a full un- 
derstanding of surgical principles and the treat- 
ment of surgical diseases It embracer in its scope 
all the diseases that are recognized as belonging to 
surgery, and all traumatic injuries. In discus:*ing 
these it has seemed to be the aim of the author 
rather to present the student with practical infor- 
mation, acd that alone, than toburden his memory 
with the views of difFereat writers, however dis 
tinguished they might have been. In this edition 



of 

eeu made 
Med. News, Jan. ISSl. 

The English edition, from which this is printed, 
has been carefully revised and rewritten; almost 
every chapter has received additions, and nearly 
one hundred new cuts introduced. The labors of 
the American editor, Dr. John B Roberts, have 
very much increased the value of the book. He 
has introduced many new illustrations and much 
new material not found in the Englisti edition. 
He has written too with great conciseness, which 
is a rare virtue in an American editor of an English 
work. If one could procure or wished only one 
surgery, i his volume would certainly be selected. 
If he def-ired two, Erich^en's Surgery would be 
added, and if he wished a third. Gross's Surgery 
would justly be the work selected. As the great 
work of Gross is amply sntHcient for the waits of 
any surgeon, the priority given to Erich^en, and 
above all others, to this work of Bryant, is no 
labored eulogy of the last volume, but a siinple and 
j ust statement of its demonstrable and pre-eminent 
merits.— 4m. Med. Bi- Weekly, Feb. 26, 1881. 



rpRIGRSEN {JOHN E.), 

-*-^ Professor of Surgery in University College, London, etc, 

THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- 
gical Injuries, Diseases and Operations. Carefully revised by the Author from the 
Seventh and enlarged English Edition. Illustrated by eight hundred and sixty-two en- 
gravings on wood. I« two large and beautiful octavo volumes of nearly 2000 pages : 
cloth, $8 50 ; leather, $10 50; half Russia, $11 50. {Now Ready.) 



Of the many treatises on Surgery which it has been 
our task to study, or our pleasure to read, there is none 
which in all points has satisfied us so well as the classic 
treatise of Erichsen. His polished, clear style, his free- 
dom from prejudice and hobbies, his unsurpassed grasp 
of his subject, and vast clinical experience, qualify him 
admirably to write a model text-book. When we wish, 
at the least cost of time, to learn the most of a topic in 
surgery, we turn, by preference, to his work. It is a 
pleasure, therefore, to see that the appreciation of it is 
general, and has led to the appearance of another edi 
tion. — Me.d. and Surg. Reporter, Feb. 2, 1878. 

Notwithstanding the increase in sine, we observe that 
much old matter has been omitt«d. The entire work 
has-been thoroughly written up, and not merely amend- 
ed by a few extra chapters A great improvement has 
been made in the illustrations. One hundred and fifty 
new ones have been added, and many of the old ones 
have been redrawn. The author highly appreciates tht 
favor with which his work has been received by Ameri- 
can surgeons, and has endeavored to render bis latest 
edition more than ever worthy of their approval. That 
he has succeeded admirably, must, we think, be the 
general opinion. We heartily recommend the book to 
both student and practitioner. — N.T.Med. Journal. 
Feb. 1878. 



The seventh edition is before the world as the last 
word of surgical science. There may be monographs 
which excel it upon certain points, but as a con- 
spectus upon surgical principles and practice it is 
unrivalled. It will well reward practitioners to 
read it, for it has been a peculiar province of Mr. 
Erichsen to demonstrate the absolute interdepend- 
ence of medical and surgical science We need 
scarcely add, in conclusion, that we heartily com- 
mend the work to students that they may be 
grounded in a sound faith, and to practitioners as 
an Invaluable guide at the bedside.— ^m. Praeti- 
tioner, April, 1878. 

For the past twenty years Erichsen's Surgery has 
maintained its place as the leading text-book, not only 
in this country, but in Great Britain. That it ig able 
to hold Its ground, is abundantly proven by the tho- 
roughness with which the present edition has been 
revised, and by the large amount of valuable mate- 
rial thai has been added. Aside from this, one hun- 
dred and fifty new illustraiions have been inserted, 
including quite a number of microscopical appear- 
ances of pathol>gical processes. So marked is this 
change for the better, that the work almost appears 
as an entirely new one. — Med. Record, Feb. 23,1878. 



■N. Y. Med. Record, April 



JJOLMES [TIMOTHY), M.D. , 

-*-^ Surgeon to St. George's Hospital, London. 

SURGERY, ITS PRINCIPLES AND PRACTICE. In one hand- 
some octavo volume of nearly lOOO pages, with 411 illustrations. Cloth, $6; leather $7 • 
half Russia, $T 50. 
This is a work which has been lookedfor on both 

sides ofthe Atlantic with muchinterest. Mr. Holmes 

la a surgeon of largeand varied experience, and one 

of the best known, and perhaps the most brilliant 

writer upon surgieal suljjects in England. It is a 

book for students — and an admirable one — and for 

the busy general practitioner. It will give a student 

all the knowledge needed to pa«6 a rigid examina- 
tion. The book fairly jaatifiesthe high expectations 

that were formed of if. Its style is clear and forcible, 

even brilliant &% times, and the conciseness needed 

to bring it within Its proper limits has not impaired 



its force and distinctness. 
14, 1876. 

It will be found a most excellent epitome of sur- 
gery by the general practitioner who has not the 
time togiveattentionto more minute and extende.d 
works, and to the medical student. In fact, we know 
of no one we can more cordially recommend. The 
author has succeeded well in giving a plain and 
practical account of each surgical injury and dis- 
ease, and of the treatment which is most com- 
monly advisable. It will no doubt become a popu- 
lar work in the profession, and especially as a text- 
book.— Cmemno^i Med. News, April, 1676, 



Henry C. Lea's Son & Co.'s Publications — {Ophthalmology). 29 
T/UELLS [J.SOELBERG], 

' ' Professor of Ophthalmology in King^s (Jollege Hospital, Stc. 

A TREATISE ON DISEASES OF THE EYE. Third American, 

from the Third London Edition. Thoroughly revised, with copious additions, by Chns. 
S. Bui], M.D. , Surgeon and Pathologist to the New York Eye ;ind Ear Infirmary. Illus- 
trated with about 250 engravings on wood, and six colored plates Together with selec- 
tions from the Test-types of Jaeger and Snellen. In one large and very handsome 
octavo volume of 900 pages. Cloth, $5 ; leather, $6 ; half Rusfcia, raised bands, $6 50. 
{Jnst Ready.) 
The long-continued illness of the author, with its fatnl terminntion, has kept this work for 
some time out of print, and has deprived it of the advantage of the revi.-ion which he sought 
to give it during the last years of hi- life. This edition has therefore bc-en placed under the 
editorial supervision of Dr. Bull, who has labored earnestly to introduce in it all the advances 
which observation and experience have acquired for the theory and practice of ophthalmology 
since the appearance of the last revision. To accomplish this, considerable additions have been 
required, and the work is now presented in the confidence that it will fully deserve a continu- 
ance of the very marked favor with which it has hitherto been greeted as a complete, but con- 
cise, exposition of the principles and facts of its important department of medicul science. 

The additions made in the previous American editions by Dr. Hays have been retained, 
including the very full series of illustrations and the test-types of Jaeger and Snellen. 

This new edition of Dr. Wells's great Wurk on the 
eye will be wetcomed by the prol'ession at large ar 
well as by the oculist. It coutains much new matter 
relating to treatment and pathology, and is brcugbt 
thoroughly up with tbe pre-ent tlatus of ophthal- 
mjiogy. Its chapter on retraction and accoramo- 
datioh — a subject much discussed of late years, aud 
of great importance — is exceedingly complete. — 
Louisville Med. News, Nov. 13, ISSO. 

The merits of Wells's treatise on diseases of the 
eye have been so universally acknowledged, and are 
so familiar to all who profess to have given any at- 
tention to ophthalmic surgery, that any discussion 
of them at this laie day will be a work of superero- 
gation. Very little that is practically useful in re- 
cent ophthalmic literature has escaped the editor, 
and the third American edition is well up to the 
times. As a text-book on ophthalmic surgery for the 
Eaglish-speakicg practitioner, it is without a rival. 
— Am. Journ. of Med. Sci., Jan. ISSl. 

The work has justly held a high place in English 
ophthalmic literature, and at the time of its first ap- 
pearance was the best treatise of its kind in the lan- 



guage. In the tecond edidon, the author showed 
industriou.-i research ia adding new material from 
every quarter, and bis .spirit was eminently candid. 
A work thus built up by honest etfort should not be 
suffered to die, and we are pleased to receive this 
third edition from the hands of Dr. Bull. His labor 
hts been arduous, a.-; the very great number of addi- 
tions bracketed with his initial testify. Under 
the editorship which the third edition has enjoyed, 
the work is sure to sustain its good reputation, and 
to maintain its usefulness. — iV^. Y. Mea. Journ., Jan. 
18S1. 

There is really no work which approaches it in 
adaptation to the wants of the general practitioner, 
while the most advanced specialist cannoc rise from 
a peru.^^al of its ample pages without having added 
to nis knowledge. The American editor. Dr. Bull, 
won his spure in ophthalmology some time back. 
His additions to the woik of the lamented Wells are 
many, judicious, and timely, and in just so much 
have ad-ded to its value. —^m. Fractitiuner, Jan, 
ISSl. 



KTETTLESHIP [ED WARD), F.R.C.S., 

-^' ophthalmic Surg, and Lect. on Ophth. Surg, at St. Thomas' Hospital, London. 

MANUAL OF OPHTHALMIC MEDICINE. In one royal 12mo. 

volume of over 350 pages, with 89 illustrations. Cloth, $2. {Just Ready.) 
The author is to be congratulated upon i.he very iDl'ormation ihey contain. We do not hesitate to 
successful manner in which he has accomplished his , pronounee Mr Wettleship's book the best manual on 
tabk; he has succeeded in being concise without i ophthalmic surgery for the use of students and 
sacriticing clearueSft, and, including t>e whole j " busy practitioners" with which we are acquain- 
giound covered by more voluminous text-books, j ted.— J.r/i. /owr. ilfe<i. »icienc(;s, April, IS80. 
nao given an excellent resume of all the practical) 



Edit- 
In one 



pARTER [R. BRUDENELL), F.R.C.S., 

^ ophthalmic Surgeon to St. George' s Hospital, etc. 

A PRACTICAL TREATISE ON DISEASES OF THE EYE. 

ed, with test-types and Additions, by John Greek, M.D. (of St. Louis, Mo.). 

handsome octavo volume of about 500 pages, and 124 illustrations. Cloth, $3 75. 
It is with great pleasure lliai we can endorse [he work chapter i.s aevoted to isiii>cus.sioLi Oj cJht- uses and selec- 
as a most vaiuable contribution to practical ophtbal- '' tion ofspectacles, and is admirably compact, plain, and 
mology. Mr. Carter never deviates from the end he has 1 useful, especially the paragraphson the treatment of 
in view, and presents the subjectin a clear and concist ! presbyopia and myopia. In conclusion, our thanks are 
manner, easy of comprehension, and hence the more | due the author for many useful hints in the great sub- 
valuable. We would fspecially commend, however, asiject of ophthalmic suriiery and therapeutics, afield 
worthy of high praise, the manner iu Avhich tne thera- 1 where of late year? we glean but a few grains of .■^ound 
peutics of disease of the eye is elaborated, for here the j wheat from amass of chaif. — New York Medical Record, 
author is particularly clear and practical, where other Oct. 23, 1875. 
writers are unfortunately too often deficient. The final I 



JDROWNE [EDGAR A.), 

-*--' ■'^nrgpon, to the Liverpool Bye and Ear Infirmary , andtothe Dispensary for Shin Diseases. 

HOW TO USE THE OPHTHALMOSCOPE. Being Elementary In- 

structionsin Ophthalmoscopy, arranged forthe Use of Students. With thirty-five iilustra* 
tions. In one small volume royal 12mo. of 120 pages : cloth, $1. 



LAURENCE'S HAMDZ-BOOK OF OPHTHALMIC i LAWSOI'^'S INJURIES TO THE EYE, ORBIT 
SUKGEKY, for the »Be of Practitioners. Second; AlfD EYELIDS: their Immediate and P.emoje 
edition, revised and enlarged With numerous | Elfects. With about one hundred illustrations, 
illustranoiis. In one very handsome oetavo vol- In one very handsome octavo volume, cloth* 
»m.e, cloth, ^ 7i. [ $3 50. ' 



so Henry C. Lea's Son & Co.'s Publications — (Med. Jurisprudence). 



'DURNETT [CHARLES H.), M.A ,M.D., 

•*-* Aural Surg, to the Presb. Hosp., Surgeon-in-tharge ofthe.Infir.forDis. of the Ear, Phila. 

THE EAR, ITS ANATOMY, PHYSIOLOGY AND DISEASES. 

A Practical Treatise for the Use of Medical Students and Practitioners. In one hand- 
some octavo volume of 615 pages, with eighty-seven illustrations : cloth, $4 60 ; leather, 
$6 50 ; half Russia, $6 00. {Lately Issued.) 



Foremost among the nnmeroas recent contribu- 
tions to aural literatnrt will be ranked this work 
of Dr. Burnett. It is impossible to do justic*> to 
this volume of over 600 pages in a necenwarily brief 
notice. It must suffice to add that the book is pro- 
fusely and accurately illustrated, the references are 
conscientiously acknowledged, while the result has 
been to produce a treatise which will henceforth 
rank with the classic writings of Wilde and Von 
Troltsch. — The Lond. Practitioner, May, 1879. 

On account of the great advances which have been 
made of late years in otology, and of the increased 
interest manifested iu it, the medical profession will 
welcome this new work, which presents clearly and 
concisely its present aspect, whilst clearly indi- 
cating the direction in which further researches can 
be most profitably carried on. Dr. Burn-tt from his 
own matured experience, and availing himself of 



the observations and discoveries of others, has pro- 
duced a work which, as a text-book, stands /aci/e 
prineex>s in our language. We had marked several 
passages as well worthy of quotation and the atten- 
tion of the general practitioner, but their number and 
the space at our command forbid. Perhaps it is bet- 
ter, as the book ought to be in the hands of every 
medical student, and its study will well repay tbe 
busy praciitioner in the pleasure he will derive from 
the agreeable style in which many otherwise dry 
and mostly unknown subjects are treated. To the 
specialist the work is of the highest value, and his 
sense of gratitude to Dr. Burnett will we hope, be 
proportionate to the amount of benefit lie can obtain 
from the careful study of the book, and a constant 
reference to its trustworthy pages. — Edinburgh 
Med. Jour., Aug. 1878. 



T 



'AFLOR {ALFRED S.),M.D., 

Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital. 

A MANUAL OF MEDICAL JURISPRUDENCE. Eighth Ameri- 

can edition. Thoroughly revised and rewritten. Edited by Johw J. Reese, M.D., Prof, 
of Med. Jurisp. and Toxicology in the Univ. of Penn. In one large octavo volume of 
933 pages, with 70 illustrations. Cloth, $5; leather, $6; half Russia, raised bands, 
$6 60. {Just Ready.) 



The American editions of this standard manual 
have for a Ioult time laid claim to the attention of 
the profession in this country; and that the profes- 
sion has recognized this claim with favor is proven 
by the call for frequent new editions of the work. 
This one, the eighth, comes before us as embodying 
the latest thoughts and emendations of Dr. Taylor, 
upon the subject to which he devoued his life, with 
an assiduity and success which made him facile 
prinreps among English writers on medical juris- 
prudence. Both the author and the book have 
made a mark too deep to be affected by criticism, 
whether it be censure or praise. In this case, how- 
ever, we should only have to seek for laudatory 
teims.— -4m. Journ. of Med. Sei., Jan. 1881. 

It is not very often that a medical book reaches its 
tenth edition, or that the last earthly labor is per- 
formed by the author in retouching the work that 
first came from his hand thirty-five years before. 
All this, however, has happened ia the ca^e of Dr. 
Taylor and his classical treatise. The pen dropped 
from the grasp only when the shadows of old age 
were rapidly deepening into the darkness of death. 
Under the circumstances, all the journalist has to do 



is to announce, not criticize the completed task. The 
value of the gem is too well known to require more 
than the telling chat the mister-hand has rebi-ighc- 
ened its facets and polished its angles before leaving 
it as his legacy to his brethren in the profession. — 
Phila Mrid. Tim<i8, Dec. 4, 1880. 

It will suffice to remark that this new edition 
shows the signs of judicious revision. A great num- 
ber of illustrative medico- legal cases which have 
occurred since the last edition was published are 
cited in cheir proper connection, and add much to 
the interest and value of the work; they comprise 
the bnlk of the additions to the text. As an indica- 
tion of the treshnesi of the work, we notice numer- 
ous references to medic )-legal experience that has 
transpired during the year j ust ended ; among these 
is a comment by the American editor upon that 
midsummer madness, the Tanner fasting exploit of 
last August. In these features and in others there 
is ample evidence that this admirable book will 
maintain its hi^h place as a standard authority con- 
cerning the matters of which it Xre-Ais,.— Boston 
Med. and Su,rg. Journal, Jan. 13, 1881. 



T>¥ THE SAME AUTHOR. 

THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- 

DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo 

volumes, cloth, $10 00 ; leather, ^12 00 . 
This great work is now recognized in England as the fullest and mostauthoritativetreatise on 
every departmentof its important subject. In laying it, in its improved form, before the Amer- 
ican profession, the publishers trust that itwill assume the same position in this country. 

73 r THE SAME AUTHOR. 

POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND 

MEDICINE. Third American, from the Third and Revised English Edition. In on© 
large octavo volume of 850 pages ; cloth, $5 60 ; leather, $6 50. 



The present is based upon the two previous edi- 
tions ; "butthecompieterevision rendered necessary 
by time has converted it into a new work." This 
statement from the preface contains all that it is de- 
sired to know in reference to the new edition. The 
works of this author are already in the library of 
every physician who is liable to be called upon for 
medico-legaltestimony (and whatoneis not?),sothat 
all that is required to be known about the present 
book is that the author has kept it abreast with the 
times. What makes it now, as always, especially 
valuable to the practitioner is its conciseness and 
practicalcharacter, only those poisonoussubstances 



being described which give rise to legal investiga* 
tions. — r/ie Clinic, Nov. 6, 1875. 

Dr. Taylor hat brought to bear on the compilation 
of this volume, stores of learning, experience, and 
practical acquai atance wi th his subj ect, probably far 
beyond what any other living authority on toxicol- 
ogy could have amassed or utilized. He has fully 
sustained his reputation by the consummate skill 
and legal acumen he has displayed in the arrange- 
ment of tne subject-matter, and the result is a work 
on Poisons which willbeindispensable to every stu- 
dent or practitioner in law and medicine, — The Dub' 
lin Journ. of Med Sa., Oct. 1875. 



Henry C. Lea's Son & Co.'s Publications — (Miscellaneous). 31 



POBERTS ( WILLIAM), M.D., 

-*-*' Lecturer on Medicine in the Manchester School of Medicine, etc. 

A PRACTICAL TREATISE ON URINARY AND RENAL DIS- 

EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Third 
American, from the Third Revised and Enlarged London Edition. In one large and 
handsome octavo volume of over 600 pages. Cloth, $4. {Just Ready.) 

THOMPSON {SIR HENRY), 

■^ Surgeon and Professor of Olinical Surgery to University College Hospital. 

LECTURES ON DISEASES OF THE URINARY ORGANS. With 

illustrations on wood. Second American from the Third English Edition. In one neat 
octavo volume. Cloth, $2 25. 
JD Y THE SA ME A UTHOR . 

ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 

THE URETHRA AND URINARY FISTULA. With plates and wood-cuts. From the 
third and revised English edition. In one very handsome octavo volume, cloth, $3 5U. 



rrUKE {DANIEL BACK), M.D., 

J' Joint author of The Mamial of Psychological Medicine, &e. 

ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON 

THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the 
Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. 

-DLANDFORD {G. FIELDING), M.D., F.R.C.P., 

J-^ Lecturer on Psychological Medicine at the School of St. George^ s Hospital , Sic. 

INSANITY AND ITS TREATMENT: Lectures on the Treatment, 

Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the 

United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very 

handsome octavo volume of 471 pages ; cloth, $3 25. 

It satisfies a want which must have been sorely ^ actually seen in practice and the appropriate treat- 

feltbythebusygeneralpractitionersofthiscountry.; ment for them, we find in Dr. Blaodford's work a 



It takes the form of a manual of clinical description 
of the various forms of insanity, with a description 
of the mode of examining persons suspected of in- 
sanity. We call pavticularattentionto this feature 
of the book, as giviugit a unique value to the gene- 
ral practitioner. Ifwepassfrom theoretical conside- 
rations to descriptionsof the varietiesof insanity as 



considerable advanceover previous writings on the 
subject. His pictures of the various forms of mental 
disease are so clear and good that no reader can fail 
to be struck with their superiority to those given in 
'Ordinary manuals in the Euglish language or (sofar 
as our own reading extends)! n any other. — London 
Practitioner, Feb. 1871. 



EA {HENRY C). 
SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF 

LAW, THE WAGER OF BATTLE, THE ORDEAL AND TORTURE. Third Revised 
and Enlarged Edition. In one handsome royal 12mo. volume of 552 pages. Cloth, 
$2 60. {Just Ready.) 

more accurate than either of the preceding, but, 
from the thorough elaboration, is more like a har- 
monious concert and less like a batch of studies. — 
The Nation, Aug. 1, 1878. 

Many will be tempted to say that this, like the 
"DeclineandFall,"isone of theuncriticizable books. 
Its facts are innumerable, its deductions simple and 
inevitable, and its chevaux-de-frise of references 
bristling and dense enough to make the keenest, 
stoutest, and best equipped assailant think twice 
before advancing. Nor is there anything contro- 
versial in it to provoke assault. The author is no 
polemic. Though he obviously feels and thinks 
strongly, he succeeds in attaining impartiality. 
Whett er looked on as a picture or a mirror, a work 
such as this has a lasting v&lae.—Lippineott' g 
Magazine, Oct. 1S78. 



This valuable work is in reality a history of civi- 
lization as interpreted by the progress of jurispru- 
dence. ... In "Superstition and Force" we have 
a pbilosophic survey of the long period intervening 
between primitive barbarity and civilized enlight- 
enment. There is not a chapter in the work that 
should not be most carefully studied, and however 
weU versed the reader may be in the science of 
jurisprudence, he will find much in Mr. Lea's vol- 
ume of which he was previously ignorant. The 
book is a valuable addition to the literature of 
social science. — Westminster Review, Jan. 1880. 

The appearance of a new edition of Mr. Henry C. 
Lea's "Superstition and Force" is a sign that our 
highest scholarship is not without honor in its na- 
ti ce country. Mr. Lea has met every fresh demand 
for hirs work with a careful revision of it, and the 
present edition is not only fuller and, if possible. 



B 



Y THE SAME AUTHOR. 

STUDIES IN CHURCH HISTORY. THE RISE OF THE TEM- 

PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large 
royal i2mo. volume of 516 pp.; cloth, $2 75. {Lately Published.) 

The story was never told more calmly or with i 'lasapeculiarimportancefortheEnglishstndent.and 
greater learning or wiser thought. Wedoubt, indeed, j is a chapter on Ancient Lawlikely tobe regarded as 
if any other study of this field can be compared with final. We can hardly pas«from our mention of such 
this for clearnese, accuracy, and power. — CWcap-o i works as these — with which that on "Sacerdotal 
E.ramtTier, Dec. 1870. ; Celibacy" should be included — without noting tb e 

Mr. Lea's latest work," Studiesin Church History," literary phenomenon that the head of one of the first 
f'lUy sustains the promise of the first. It deals with i American houses is also the writer of some of its most 
three subjects— the Temporal Power, Benefit of 1 original books.— iondon ^i^iencewm, Jan. 7, 1871. 
Clergy, and Excommunication, the record of which I 



32 



Henry C. Lea's Son & Co.'s Publications. 



I]>TDEX TO CATALOGUE 



real 



American. Journal of tlie Medical Sciences 

Allen's Anatomy 

Anatomical Atlas, by Smith and Hornt 
Ashton on the Rectum and Anus 
Attfield's Chemistry .... 
Ashwellon Diseases of Females 
*A.shhurst's Surgery .... 
Browne on Ophthalmoscope . 
Browne on the Throat . 
*Burnett on the Ear 
*Barne8 on Diseases of "Women . 
Barnes' Midwifery .... 

Bellamy's Sargical Anatomy 
*Bryant'sPractice of Surgery . 
Bloxam's Chemistry .... 
Blandford on Insanity .... 
Basham on fienal Diseases . 
Bartholow on Electricity 
Barlow's Practice ol Medicine . 
Bowman's (John E.) Practical Chemistry, 
*Bristowe'& Practice .... 
*Bamstead on Venereal 
Bamstead and CuUerier's Atlasof Ve: 
■^Carpenter's Human Physiology 
Cdrpenter on the Use and Abuse of Alcohol 
*Cornil and Ranvier .... 

Carter on the Eye 

Cleland's Dissector .... 
Classen's Chemistry .... 
Clowes' Chemistry .... 
Coleman's Dental Surgery . 
Century of Americaa Meaicine . 
Chadwick on Diseases of Women 
Chambers on Diet and Kegiiiien . 
Christison and Griffith's Dispensatory 
Churchill on Puerperal Fever 
Condie on Diseases of Children . 
Cooper's (B. B.) Lectures on Surgery 
Callerier's Atlas of Venereal Diyeases 
Duncan on Diseases of Women . 
*Dalton's Human Physiology 
Davis's Clinical Lectures 
Dewees on Diseases of Females . 
Druitt's ModernSurgery 
*Dunglison's Medical Dictionary 
Edis on Diseases of Women . 
Ellis's Demonstrations in Anatomy 
*Erichsen'8 System of Surgery , 
*Emmet on Diseases of WoEieu . 
Farquharson's Therapeutics 

Foster's Physiology 

Fenwick's Diagnosis .... 
Finlayson's Clinical Diagnosis 

Flint on Respiratory Organs 

Flint on tlie Heart .... 

*?'lint's Practice of Medicine. 

Flint's Essays 

*Flint's Clinical Medicine . 

Flint on Phthisis 

Flint on Percussion .... 

*Pothergiirs Handbook of Treatment 

Fownes's Elementary Chemistry 

Fox on Diseases of the Skin 

Fuller on the Lungs, &c 

Green's Pathology and Morbid Anatomy 

Greene's Medical Chemistry 

Gibson's Surgery 

Gluge's Pathological Histology, by Leidy 

*Gray'8 Anatomy. 

Galloway's Analysis .... 

Griffith's (R. E.) Universal Formulary 

Gross on Sterility 

Gross on Urinary Organs 

Gross on Foreign Bodies in Air-Passages 

*3ross's System of Surgery 

Habershon on the Abdomen . . 

^Hamilton on Dislocations and Fractures 

Hartshorne's Essentials ofMedicine 

Hartsnorne's Conspectus of the Medical Sci 

Hartshorne's Anatomy and Physiology 

Hamilton on Nervous Diseases . 

Hoffman's Chemical Analysis 

Hesth's Practical Anaconiy 

Hoblyn's Medical Dictionary . 

Hodge on Women 

Hodge's Obstetrics 



1 

7 

7 
26 

9 
21 
26 
29 
19 
30 
22 
24 

7 
28 
10 
31 
20 
18 
14 

9 
14 
20 
20 

S 
11 
13 
29 

7 

9 
10 
26 

24 
20 
11 
21 
20 
2o 
20 
23 
8 
15 
21 



Holland's Medical Notes and Reflectioas . 
*Holmes' System of Surgery 
^Holmes's Surgery . ... 

Holden's Landmarks .... 

Horner's Anatomy and Histology . 

Hudson on Fever , 

Hill on Venerea] Diseases .... 
Hillier's Handbook of Skin Diseases 
Jones (C. Hahdfield) on Nervous Disorders 
Knapp's Chemical Technology . 

Keating on Infants 

Lea's Superstition and Force . . 
Lea's Studiesin Church History 

Lee on Syphilis 

*Leishman'8 Midwifery .... 



PAGB 

14 

. 27 



La Roche on Pneumonia, &c. 

Laurence and Moon's Ophthalmic Surgery 

Lawson on the Eye . . . 

Lehmann's Physiological Chemistry, 2 vols. 

Lehmann's Chemical Physiology 

Ludlow's Slanual of Examinations . 

Lyons on Fever 

Maisch's Materia Medica 

Miichell's Nervous t)iseases of Women 

Medical News and Ab-siract 

Morris on Skin Diseases 

Meigs on Puerperal Fever . . . / 

Miller's Practice of Surgery 

Miller's Principles of Surgery . 

Montgomery on Pregnancy 

Nettleship's Ophthalmic Medicine 

Neilland Smith's Compendium of Med. S 

Parviu's Midwifery . . 

Parry on Extra-Uterine Pregnancy . 

Pavy on Digestion 

*Parrish's Practical Pharmacy . 

Pirrie's System of Surgery . 

*Playfair'8 Midwifery .... 

Quain and Sharpey's Anatomy, by Leidy 

*Reynold8' System of Medicine . 

Richardson's Preventive Medicine 

Roberts on Urinary Diseases 

Ramsbotham on Parturition 

Remsen's Principles of Chemistry 

Rigby's Midwifery .... 

Rodwell's Dictionary of Science . 

Stimson's Operative Surgery 

Swayne's Obstetric Aphorisms . 

Seller on the Throat 

Sargent's Minor Surgery 

Sharpey and Qnain's Anatomy, by Leidy 

Skey's Operative Surgery . 

Slade on Diphtheria .... 

Schafer's Histology . . . . , 

*Smith (J. L.) on Children . 

Smith (H. H.) and Horner's Anatomical Atlas 

Smith (Edward) on Consumption 

Smith (East ) on Wasting Diseases in Children 

*Still6's Therapeutics 

*Stille & Maisch's Dispensatory . 
Starges on Clinical Medicine 

Stokes oa Fever 

Tanner's Manual of Clinical Medicine 
Tanner on Pregnancy . 
*Taylor'8 Medical Jurisprudence 
Taylor's Principles and Practice of Med 



20 



14 i Taylor on Poisons 



6 

9 

11 

20 
26 
26 
26 
14 
25 
16 
5 5 

7 
18 
11 

6 

4 
22 
24 1 



Take on the Influence of the Mind 

^Thomas on Diseases of Females 

Thompson on Urinary Organs 

Thompson on Stricture .... 

Todd on Acute Diseases 

Woodbury's Practice .... 

Walshe on the Heart . . • . . 

Watson's Practice of Physic 

*Wells on the Eye .... 

West on Diseases of Females 

Weston Diseases of Children 

West on Nervous Disorders of Childrej 

Williams on Consumption . 

Wilson's Human Anatomy . 

Wilson's Handbook of Cutaneous Medicin 

Wcihler's Organic Chemistry 

Winckelon Childbed .... 



18 

2 
19 
21 
25 
25 
21 
29 

5 
24 
'12 
14 
11 
25 
24 

7 
17 
16 
31 
23 

9 
21 

4 
25 
21 
19 
26 

7 

25 

16 

7 

21 



18 
20 
13 
12 
15 
14 

6 
23 
30 
30 
30 
31 
22 
.^1 
.31 
14 
16 
16 
16 
29 
21 
21 
21 
16 

7 
26 



21 



Books marked * are also bound in half Russia. 



HENKY C. LEA'S SON & CO.— Philadelphia. 



